Medical Acupuncture is a good book, and a very bad book. It is collection of essays dealing with acupuncture from a biomedical perspective, obviously directed at a biomedical audience. One senses that the authors have recognised the power of acupuncture, but feel uneasy with this given the frequent scorn with which it is treated by their medical peers, and the conflict of traditional oriental paradigms with their biomedical biases. Therefore, the attempt is made to make acupuncture 'respectable' as a biomedical modality. There are two basic aspects of this book. The positive aspect is that it brings together a great amount of understanding gained about acupuncture within the scientific framework, including clinical research. A great number of topics are covered, and in this respect the book is a useful reference source for acupuncturists of all persuasions.
The negative side of the book is the promotion of the view that traditional Chinese paradigms are only empirical, and otherwise invalid. It may be that not all contributors to the book would agree with this outlook, but it is certainly the expressed position of the editors, who write: "It is hoped that this textbook celebrates the emergence of acupuncture from its mystical, alternative roots and hastens its complete integration into conventional medicine over the next decade." This theme, inherent in the book as a whole, is elaborated upon by one of the editors, Adrian White, in a promotional article. He accepts the observational skills and accumulated experience of traditional Chinese physicians, but dismisses their theoretical framework as an explanation of how acupuncture works. There is "not the slightest evidence to support the traditional ideas. Despite detailed research, there is simply nothing that can be found to suggest that energy really does circulate in meridians, or that diseases can be caused (for example) by an attack of dampness". Traditional explanations, based on Daoist philosophy, are "unacceptable in the face of current knowledge". There is a need for reappraisal employing the biomedical paradigm. "This reappraisal of acupuncture extends beyond how acupuncture should be practised and what its mechanism might be. It incorporates a modern approach to health care, which recognises the need to provide clinical trial evidence to back up anecdotal reports of acupuncture's successes. Only by providing evidence can acupuncture stand alongside other therapies that are established, and be judged by the strictest criteria of evidence-based medicine".
When an extraordinary claim is made - in this case, that the accumulated theoretical understanding gained over thousands of years by one of the greatest civilisations is all incorrect - extraordinary diligence is required to substantiate it. What does one make, then, of the statement in the article Acupuncture in Context by C. Chan Gunn: "'Lung' in TCM does not relate to diseases of the respiratory system, but to skin diseases; 'Kidney' is not concerned with the urinary tract, but with the genital system…" These statements are patently incorrect, as would be evident to first year students on any reputable acupuncture course (but maybe not to GP's on a four weekend course). These statements make Chinese theory look peculiar, limited and quaint to a biomedical audience, but the most important thing is that they are wrong. One can only conclude that the author does not have even an elementary understanding of the topic he is discussing. The editors must also take responsibility for mistakes such as these.
Interpreting one paradigm by another presents special problems. As Thomas Kuhn has shown in his book The Structure of Scientific Revolutions, no paradigm is complete and cannot answer all questions that can be asked of it. Furthermore, different paradigms are incommensurable, meaning that their concepts cannot be directly translated one to another. 'Qi' does not mean 'energy'; 'Xue' does not mean 'blood' in the standard physiological sense. The 'Channels' of acupuncture are not the two-dimensional conduits envisaged by scientists who attempt to find them anatomically or in other scientific terms. 'Yin' and 'Yang' aren't things that can be straightforwardly specified biomedically. These Chinese concepts cannot be easily defined explicitly; as in any complex paradigm, their meaning and relevance are intrinsic to their use in the entire context of their paradigm. Any intellectually responsible attempt to deal with Chinese medical theory must acknowledge this. It is as inappropriate to try to translate traditional Chinese theory into biomedical terms as to square a circle. Given the pretensions of this book, it was the authors' responsibility to acknowledge and grapple with such difficulties. Instead, the disreputable approach of sloughing off the problem has been adopted. Traditional Chinese concepts are dismissively characterised as "mystical", "naive", "inscrutable", "anachronistic and not compatible with modern science". It doesn't take long for the inter-paradigm dilemma of incommensurability, that was not really recognised or acknowledged in the first place, to be forgotten altogether. The fact that many 'medical' acupuncturists go on in real life to similarly argue that patients should only consult acupuncturists who are orthodox doctors reveals the hidden impulse behind much of this - the usual tendency of the biomedical profession to attempt to assert a monopolistic position.
The dramatic increase in popularity of alternative medicine in the past 25 years is a threat to the supremacy of biomedicine. It is accompanied by a disillusionment with science. There are two inter-related movements arising within biomedical circles in response to this. One is the call for 'Integrated Medicine', the other for 'Evidence Based Medicine'. At first sight, both seem reasonable and respectful of complementary and alternative medicine (CAM) modalities. The superficial argument is that if a CAM can objectively be shown to work, it can or even should be absorbed within the mainstream. Prof. Stephen Holgate, a member of the steering committee that produced the report Integrated Medicine - A Way Forward for the Next Five Years?, has written: "If we are going to bring complementary and alternative medicine into mainstream health care then we have got to have the evidence, otherwise the health service is not going to invest in it. We have got to show that it works, how it works, and for which indications it works best." (BMJ Volume 315, 1 November 1997). This typical argument begs many issues. Mainstream medicine is practised within a specific paradigm. Research is expected to adhere to orthodox assumptions, at which point the biomedical paradigm has already established its dominance. Medical authorities are rarely satisfied by simply finding if a CAM works; there is a further call to determine 'how it works' (from a modern scientific point of view), which reinforces the biomedical paradigm's controlling grip. At a certain point, it is likely that the original paradigm will be abandoned, 'now that the technique has been put on a firm scientific footing'. Inter-paradigm issues are thus avoided; biomedicine has reasserted control. But a paradigm is much more than a technique; all paradigms make implicit assumptions that are reflected back into a resultant world view. These world views with their associated concepts are incommensurable from paradigm to paradigm. The richness, subtleties and insights of Chinese medicine must be lost if the biomedical paradigm is imposed upon it. A traditional holistic system will be replaced by something mechanistic, materialistic, and reductionist.
Medical Acupuncture provides a good example of how a discipline like traditional acupuncture could easily develop within the ethos of Evidence Based Medicine and Integrated Medicine - acupuncture without its Qi and Blood, without its Jing and Shen, without its Zhi-wisdom. It is important that traditionalists heed this, recognising that they must fight for the right of their own paradigms to be properly represented and fully respected. The tragedy is that it is necessary to say this. We live in a multicultural society in which religious and intellectual tolerance are given official recognition. Yet many scientists feel justified in imposing their own belief system upon everyone else with a self righteousness reminiscent of the excesses of religious fundamentalism. It takes a new level of intellectual maturity to accept that every paradigm is self-contained and self-referential, and that it is not necessary to obliterate one in order to validate another. If one can accept that individual paradigms provide unique insights and practical uses, one can benefit from each one. We don't feel a need to only listen to Western music and not Chinese; both are music, although the instruments are tuned differently. Cross-fertilisation is also possible. The insights of scientific research can inform the practice of a traditional acupuncturist, and vice versa, without there being conflict. Surely this way forward is superior to the ambition of many 'medical' acupuncturists to usurp the field. 'Medical' acupuncturists could signal their change of heart by at least calling themselves 'biomedical' acupuncturists, not appropriating a term that applies equally to all forms of medicine.
I end by considering Felix Mann's contribution to the book. He presents his personal ideas about acupuncture, gained after years of practice. We are indirectly reminded of the empirical, experiential element that is fundamental to all medicine practised as an art and not just a science. Those who would have us practise only according to modern scientific dictates would do well to take note of Mann's remark: "It is apparent, I hope, that in acupuncture there are many roads to Rome."
Reviewed by Wainwright Churchill