Acupuncture And Evidence-Based Medicine: A Philosophical Critique

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Acupuncture And Evidence-Based Medicine:
A Philosophical Critique
2002
Michael T. Greenwood, MB (MD), BChir, CCFP, CAFCI, FRSA
Medical Acupuncture

ABSTRACT
The current popularity of evidence-based medicine poses a challenge for acupuncture and other interactive therapies. This article explores the assumption of objectivity involved in gathering evidence, suggests that objectivity is an inappropriate standard for acupuncture, and concludes that where acupuncture and other interactive therapies are concerned, the objective/subjective dichotomy is perhaps transcended.

KEY WORDS
Acupuncture, Evidence-Based Medicine, Objectivity, Subjectivity, Relational Holism

INTRODUCTION
Evidence-based medicine (EBM) appears to be gathering momentum. Regimens and protocols are becoming the norm, and physicians are encouraged to consult the protocols before initiating treatment. Supporters of this approach argue that given the multiple and sometimes confusing studies available on any particular subject, guide lines based on a review of latest scientific evidence will lead to an improvement in patient outcomes and more cost-effective medical care.1 However, physicians may not search for evidence even when it is available, remaining privately skeptical.2 Indeed, authors in the British Medical Journal have reservations, perhaps that EBM is now so familiar a term that it is easy to forget to ask what data provide appropriate evidence for particular decisions.3

Whatever the eventual role of EBM in regular medical practice, the application of guidelines to acupuncture is challenging because its philosophical base requires the practitioner to transcend the objective principles inherent in standardized point protocols. Certainly, the same could be said for any medical practice because ultimately, all medicine involves a unique relationship between practitioner and patient. The difficulty is that medicine is an art as much as a science, a subjective experience as much as an objective discipline. Experienced physicians discover they must synergistically combine their scientific knowledge with intuition if they are to discover the secrets of healing. Georg Groddeck, a contemporary of Freud, states it this way:

"... it is good, at least once in a lifetime, to stand quietly by, and as far as possible to give oneself up to the consideration of how things happen outside our knowledge or our power. For us physicians in particular, that is essential,...because otherwise we run the danger of being one-sided, of deceiving ourselves and our patients, by saying that just this or that mode of treatment is only the right one...It sounds absurd, but it is nevertheless true, that every kind of treatment is the right one for the sick man, that he is always and in all circumstances rightly treated, whether according to the methods of science or the methods of the old wife."4

The Assumption of Objectivity
The evolution of EBM has been characterized as a medical paradigm shift that establishes the supremacy of the double-blind, randomized controlled clinical trial over studies of lesser objective status such as cohort, observational, descriptive, or the anecdotal.5 According to conventional wisdom, the most reliable evidence of treatment efficacy arises from gold-standard trials, the least reliable from the anecdote. Yet in some ways EBM looks more like the rear-guard action of an ossified paradigm fiercely resisting change.

First, there is something disturbing about a healing profession that relies solely on objectivity as a gold standard for anything, for the simple reason that modern physics maintains that objectivity simply does not exist. Indeed, through physics, scientists have come to understand that the observer inevitably influences what is observed, tilting the results toward a pre-existing cognitive bias of the observer.6 Although this principle is well recognized in other scientific disci-plines, the implications of observer influence continues to be ignored by modern medicine.

Second, objective research produces information only at the simplest, most superficial level, the material outward appearance. Such evidence is only useful for simple, well-structured problems, such as drug treatment for relatively well-defined and straightforward clinical situations. The more complex and multifactorial a situation, the less such an objective approach is useful. Since many modern stress-related illnesses arise out of complex and multidimensional factors, the rigid adherence to objectivity as a gold standard is difficult to justify.

Third, because illness is a subjective experience, to suggest that subjectivity is not as important as objectivity is to deny the whole illness experience. Yet such denial seems to be accepted without question by some in the medical profession.
The pressure exists to submit interactive therapies such as acupuncture to double-blinding, a process that cannot be done without destroying the therapy's essential essence. Such pressure is usually justified by the erroneous idea that all good medicine should be open to objective scientific scrutiny, and that resistance to such scrutiny implies that the practice is based in charlatanism. The following is a typical example of conventional opinion on complementary and alternative medical (CAM) therapies:

"Let those who endorse CAM practices produce valid evidence as to the efficacy and safety sufficient to satisfy these groups (peers and regulatory bodies). If and when that happens, those practices will be integrated without difficulty as part of good mainstream medicine; for then they will no longer be alternative."7

But because objective study destroys the essence of interaction, conclusions arising from objective research into interactive therapies are meaningless. Yet negative "objective" conclusions can find their way into evidence-based guidelines, have been used by insurance companies to deny payment for physician services, and can be manipulated by regulatory authorities to control physicians' practice style. For example, a trial concluding that acupuncture was ineffective for rheumatoid arthritis was reported in the Acupuncture Foundation of Canada newsletter as "research we don't need."8 The study was detailed except that the acupuncture regimen consisted of a single needle at point LV 3. The researchers falsely concluded that this was acupuncture. Similar inappropriate research has been used to compare different interactive techniques. For example, a study comparing massage with acupuncture concluded that massage was superior without considering the crucial factors of context, relationship, intention, or the fact that most of the acupuncturists felt constrained by the parameters of the study.9 The study troubled participants on the AAMA chat lines (perhaps because people realized that the conclusions were erroneous without being able to pinpoint why). All of this is unacceptable, yet the profession as a whole has been unable to resist the effects of illogical studies, in part because it pays homage to the principle of objectivity on which such research rests.

While few people would argue against the value of performing double-blind trials on new drugs before releasing them for public use, it is a different matter to try to double-blind interactive therapies. Even if blinding were possible, without the potential of an investment payback such as there might be with a new drug, there is little incentive for anyone to do it. Thus, since it is only drugs that fit the testing method, EBM has become unjustifiably biased toward drugs.

The salient point is that inability to be double-blinded does not mean interactive therapies do not work. It means they cannot be studied objectively. Nor do they need to be, since they pose less potential harm to the consumer compared with the effects of an untested chemical. It is not prudent to dismiss them because they do not fit a drug-research model. There are other valid ways of perceiving, gathering evidence, and deciding if a treatment is valuable. Perhaps the fact that these other ways are not given equal place in our thinking and in our journals is without justification and irrational. Maybe objective measurement is currently in vogue not because it is more valid, but because it carries the force of collective popularity.

Complete article may be viewed online.