Reconciling science & Chinese medicine
For many years I have been dogged by an unresolved conflict: that between allegiance to the systematic evidence-based, mechanistic approach of ‘science’ and the more faith-based, energetic (and sometimes ‘airy-fairy’) one of ‘alternative’ and Chinese medicines.
This conflict has got me into numerous arguments – including quite a few with myself – and writing articles has helped me to resolve it. This has been a transformative and liberating experience for me. Inner conflicts can be hard work.
Our profession is also in conflict as regards science. It seems to me that a sizeable proportion of practitioners have a sceptical and even hostile attitude towards science – they tend to be resistant to scientific scrutiny. Many more are ambivalent.
There is nonetheless a growing recognition that we, as a profession, need to adopt a more scientific approach in order to defend Chinese medicine against assaults on its legitimacy.
Having myself been highly sceptical about the institution of science, I now strongly believe this is the path we must take. I also believe we need to be much more resolute in pursuing it.
Like it or not, in order to thrive – and maybe even survive – Chinese medicine in the West needs to reconcile itself to the fact that, as the predominant legitimating institution, science holds most if not all of the cards.
Riding the pendulum of belief
I have always felt strongly about science. In the 1960s, I studied science A levels, then sociology and philosophy of science, firmly committed to the scientific perspective. As an educational researcher, I conducted the highly statistical Reading Surveys of England and Wales (1970–72).
However, when I got involved in the New Age Movement in the mid-1970s, I became not just disillusioned with medical science but vehemently anti-science. When I started practising acupuncture in the late 1980s it was easy to maintain this cynical stance. Medical science had invited particular criticism from the 1950s onwards due to the reckless overprescribing of drugs like barbiturates, tranquillisers, steroids and thalidomide.
Along with many ‘alternative’ therapists, I dismissed medical science and orthodox medicine in general as mechanistic and reductionist, self-aggrandising and unempathetic, in hock to Big Pharma, and gung ho with the prescription pad. I also uncritically parroted alternative medicine’s mantra ‘treat the cause, not the symptom; the person, not the disease’ – a view I questioned in an article in EJOM, 10,1. More recently, I have been radically reassessing this one-sided view.
Through the last half of the twentieth century, nutritional science (backed by the food industry) clung doggedly to the now discredited scientific orthodoxy that excessive fat – not sugar – was the foremost dietary cause of heart disease. This was despite mounting evidence to the contrary and the burgeoning obesity epidemic. (‘The Sugar Conspiracy’, The Guardian, 7.4.16)
It is true that medical science has sometimes too readily endorsed suspect treatments and has served interests other than the pursuit of truth. It has also made overblown claims about its proficiency and objectivity. This behaviour has created unrealistically high expectations that have inevitably resulted in a backlash of disillusionment and distrust.
Despite an avowed ethos of open-mindedness and critical self-appraisal, medical science has sometimes been stubbornly closed to new ideas. For example, it has sometimes victimised those it regarded as heretics, such as John Yudkin who, in 1972, challenged the now discredited scientific orthodoxy that ingested fat – as opposed to excessive refined carbohydrate intake – was the foremost dietary cause of heart disease.
Nonetheless, I began to realise that ‘alternative’ medicine’s tendency to overly focus on science’s aberrations and shortcomings – sometimes to the point of demonising it – has led to its strengths often being overlooked.
Science and ‘scientism’
I had fallen into the trap ensnaring many a lofty idealist: totally rejecting something because it is flawed. More precisely, I had been confusing science with ‘scientism’: a term applied when ‘science’ – or what purports to be science – overreaches itself and expands beyond its proper boundaries. This occurs when science’s capabilities are overstated, its kudos is appropriated, its modes of understanding are universalised, or its methodology is inappropriately applied.
Science’s idealised image has allowed it to function as a marketing brand conferring value on any idea, technique or product to which it can credibly be attached. More ardent advocates and starry-eyed admirers have at times endowed science with an all-seeing, godlike potential to divine the truth and fix all ills. Scientists have been accorded magical powers once attributed to sorcerers and soothsayers.
However, strip away the excesses and there is a very positive side to science: a spirit of inquiry and critical appraisal backed by institutional safeguards like peer review and stringent methodological guidelines. The latter are designed to counter bias and ensure evidence is gathered in a systematic, transparent, replicable way. And when individuals inevitably err, this institutional framework limits the leeway for this. Of course, there is also a need to adapt scientific methodology to fit the subject matter in question – and to recognise that there are severe limits to what can be measured.
This approach of separating the purer, humbler essence of science from its overblown alter ego ‘scientism’ seems far preferable to throwing the baby out with the bathwater.
Filtering fact from fancy
Medical science may well be biased against ‘alternative’ therapies but its methodology has also been applied against unscrupulous pharmaceutical companies – albeit sometimes somewhat tardily – to expose their spurious claims. Paradoxically, it might even ultimately serve the cause of alternative medicine by reining in irresponsible and deluded therapists who make extravagant, unsubstantiated claims.
Despite its limitations, scientific methodology, when appropriately applied, generally provides a more transparent, less fallible means of filtering fact from fancy than the alternatives. Most of these rely largely on anecdotal, non-systematically gathered evidence, faith, intuition and conjecture, with no formal controls for bias.
Chinese medicine is largely legitimated by tradition, having been tried and tested over centuries. But although probably largely effective, this validation method is non-systematic and as we know, carries much less weight in the West.
Scientific methodological procedures may not ensure consistent reliability and validity but they do represent concerted, regulated and replicable attempts to achieve these. For instance, repeating studies or testing the same hypothesis using different research designs enables the retrospective identification of outliers, whose findings are liable to be suspect.
The downside is that medical science in practice tends to be in a rush to extensively market newly patented medications. Often insufficient time is allowed for adequate testing – and retesting – and strict safety monitoring.
Fairness on both sides
‘Alternative’ medicine has tended to focus on the dangers of orthodox medical techniques – sometimes overlooking the dangers that might stem from failing to use them or resorting to them too slowly. Antibiotics, for instance, have been vilified despite their sometimes crucial life-saving properties.
Underlying this standpoint is the utopian assumption that medicine can be risk-free, yet still effective; that it can have benefits without costs, effects without side effects. While this may be true to a limited extent – especially in fundamentally healthy individuals – for serious, entrenched diseases like cancer, as yet, there seems to be no uncompromised elixir. Treatments without side effects are unlikely to have much or sufficient positive effect either. Where thought necessary, TCM clinicians in China prescribe western medications alongside traditional treatments.
Western medicine has learned from some of its mistakes – now recognising, for instance, that antibiotics undermine immunity. And Chinese and ‘alternative’ medicines have played important roles in pointing to the shortcomings of medical science: the hegemony of orthodox medicine has been challenged with some success.
But proponents of alternatives – myself included – have sometimes been markedly reluctant to acknowledge their limitations or the benefits of medical science. Is it reasonable – and realistic – for us to expect open-mindedness and even-handedness from medical science if we stay in our tribe, remaining closed to it and dismissive of its benefits? A sense of fairness cuts both ways.
If you can’t beat them…
In the contest for legitimacy, medical science ultimately holds the trump card. As the predominant legitimating institution, it largely determines the way in which medical resources are allocated. It also affects the willingness of the medical profession and media to endorse any form of treatment, including non-orthodox.
No matter how sceptical, wary or mystified we Chinese medicine practitioners are as regards medical science, the scientific establishment is becoming increasingly difficult to ignore or sidestep, not least because of the tightening regulatory framework.
One relatively recent restriction in Britain is that practitioners are not allowed to publicly claim they can treat or even address a condition unless they can refer to consistent, scientifically validated evidence. This requirement surely provides us with an added incentive to accelerate the adoption of a more systematic evidence-based approach; and to engage constructively with the medical and scientific establishments to persuade them to adopt more appropriate and even-handed ways of evaluating Chinese medicine.
RCTs and the placebo fixation
A major sticking point is that advisory agencies like the National Institute for Health and Care Excellence (NICE) insist on the use of the random, placebo controlled, double-blinded trial (RCT) with ‘sham’ acupuncture as placebo. They have made the questionable assumption that the reason ‘sham’ acupuncture significantly outperforms more mundane placebos like sugar pills is due solely to it creating greater positive expectations.
Lobbyists representing the acupuncture profession have claimed instead that far from being inert, so-called sham acupuncture has effects similar to those of real acupuncture. This is liable to result in the underestimation of the effect size of the ‘real’ form when compared to the ‘sham’.
Another problem is that RCTs do not readily accommodate Chinese medicine’s bespoke approach of tailoring treatments to fit individual patients. This is because the RCT format is designed to test one-size-fits-all standardised therapeutic interventions. This means that much of the expertise and ingenuity underpinning the practice of Chinese medicine – often crucial to its success – is factored out by the research design.
It has been extensively argued that a more appropriate way of assessing the effectiveness of multi-component, skills-based therapies such as acupuncture, psychotherapy and surgery is to use ‘pragmatic trials’. In these trials, outcomes are compared with those of other therapies or ‘usual care’ in real-world settings, rather than with artificial experimental ones. This allows therapists to use their clinical judgement to tailor their treatments to meet patients’ individual needs. The contribution to healing outcomes from the ‘therapeutic relationship’ and related factors like lifestyle advice are also acknowledged as valid. Pragmatic trials also avoid the ethical concerns and methodological problems associated with using placebos.
That said, despite their limitations – and alleged incongruence with acupuncture – RCTs have one major advantage over pragmatic trials. Although limiting the ability to generalise their results to real-world settings, their strictly controlled nature allows control for confounding variables – in addition to the placebo effect – which might lead to biases and spurious associations.
Whereas pragmatic trials are suited to ascertaining whether therapies are effective overall, RCTs can within limits determine which particular aspects of treatment are effective and to what extent. These benefits – and the likelihood RCTs will persist as a political fact of life – provide compelling reasons for seeking to reconcile them with acupuncture, an approach advocated by the Society for Acupuncture Research.
This will not be easy, given the seemingly intractable problem of finding a mutually acceptable acupuncture placebo or, alternatively, convincing medical science that placebos may potentially introduce more sources of error than they counteract. Another approach is to challenge the whole, rather nebulous notion of the placebo effect, seen by some scientists as highly problematic.
Unfortunately, in recent years NICE has been remarkably unreceptive to the profession’s entreaties for a fair hearing on these issues. The validation criteria it has applied to acupuncture especially since 2016 can be seen as not just inappropriate but inconsistent, discriminatory and arbitrary.
This is not so true of some other advisory agencies like the National Institutes of Health (NIH), the US government’s medical research agency. NIH has acknowledged the unresolved inadequacies of RCTs – it now prioritises pragmatic trials for acupuncture and ‘strongly discourages’ research submissions comparing verum and sham forms. Perhaps there may be an element of open-mindedness in the scientific community that can be appealed to.
The Acupuncture Wars
The Chinese medicine community in the West is deeply divided in its attitudes towards science, a situation documented by Linda Barnes in her Massachusetts-based study, The Acupuncture Wars (2003).
Barnes observes a polarisation between a substantial proportion of practitioners who take a resolutely oppositional stance towards science and those who seek to come to an accommodation with it with a view to gaining greater legitimacy in the eyes of scientific and medical establishments. She quotes Bob Flaws who caricatures the former (perhaps unfairly) as those who ‘practise Oriental Medicine as part of a larger “spiritual journey to the East”’ as distinct from ‘secular professional medicine’.
A study by Jackson and Scrambler (2007) suggests resistance (and ambivalence) to scientifically endorsed, evidence-based validation may also be common among British practitioners.
Those practitioners taking a hard-line stance against scientific encroachment believe Chinese medicine can not be reconciled with its culturally imperialistic rival. They fear attempts to find common ground is liable to result in Chinese medicine’s ‘subordination to (biomedical) paradigms with which it has little in common’ (Barnes). They continue to meet the challenge of unwelcome scientific scrutiny by withdrawing into a defensive enclave. To secure limited legitimacy, they piggyback on the more faith-based belief system of ‘alternative’ medicine.
This strategy has become less viable as scientific scrutiny has been growing. In response, there has been an increasing tendency among practitioners – spearheaded by their more politically conscious professional organisations – to meet this mounting challenge to their legitimacy by engaging in scientifically validated research themselves.
Playing science at its own game
The main thrust of this scientific research has been directed towards evaluating the therapeutic effectiveness of the techniques and treatment protocols of Chinese medicine. However, there has been relatively little, if any, energy put into mounting a scientifically grounded defence of the conceptual framework which originally spawned these techniques and protocols – the very framework that continues to inform the way they are most effectively employed.
There is a need to speak to scientists in a language they understand and to take on science at its own game. The logic of science – that has led to qi, the climatic analogy and other building blocks of Chinese medicine’s theoretical framework being dismissed as ‘pseudo-science’ or mysticism – can equally be harnessed in their support.
The failure to mount an effective scientifically literate defence of Chinese medicine’s conceptual foundation leaves it more vulnerable to exactly what those practitioners hostile to and wary of science fear: that it will be subsumed under biomedicine’s own paradigms. This could mean acupuncture becoming a bog standard technique in biomedicine’s therapeutic armoury – earmarked predominantly for pain relief – and Chinese medicine in general reduced to a dubious adjunct wheeled out when conventional approaches fail.
The war within: resolving inner conflict
I have come to see my evolving relationship with science as an inner, personal journey: a quest to reconcile East and West, Chinese medicine and science, within myself as well as on an institutional level.
The splits and conflicts within my psyche have mirrored those occurring between science and Chinese medicine and within the profession itself. It is a journey that many of my fellow acupuncturists have also been undertaking.
My views have ranged from idealisation to demonisation, from blanket rejection to conflicted ambivalence. You name it, I have the banner and T-shirt!
Hopefully, I have now achieved a more nuanced, balanced and open-minded view. I believe, perhaps naively, that science is not the intrinsically doctrinaire and absolutist monolith I once considered it to be. Instead, I see it as a broad church, sufficiently flexible and open – if persuaded – to accommodate Chinese medicine within its overarching philosophical and methodological frameworks.
I may well be being wildly optimistic but I can envisage concepts like qi and the climatic analogy one day featuring in scientifically validated theories. Coming up in EJOM 10,2, I will attempt to give some credence to this prospect by making a case for qi to be considered as a potential scientific concept.
Mind you, I may not have remained so optimistic if I had been one of those valiant BAcC negotiators combatting the uninformed and stubbornly blinkered stance of NICE.
This article is mainly based on a longer one originally written for the European Journal of Oriental Medicine: ‘The Battle for Legitimacy: Science, Medicine and the Politics of Validation’ (EJOM 9:6, 2022). My special thanks to Charlie Buck and Ian Appleyard for providing valuable background information, particularly on their frustrating negotiations with NICE.
All artwork for this article is created by the author.