Does epistemology sound scary - intriguing - or like jargon? Whatever your point of view is, here is an explanation: epistemology at its root, means to take a stand in relationship to a subject (epi-steme). In order to do that, one must develop knowledge about that subject. Put differently, epistemology is how we build knowledge.
Language is an important tool for building and communicating oral and printed knowledge. In this case, words are a critical piece of medical inquiry, which relies on technical and professional language. The words give form to the history, details of assessment, development of the treatment plan and the treatment. I would like to address Chinese and Western medical terminology in relation to practice and policy.
Practitioners employ language to describe the signs and symptoms, make a diagnosis, and treatment plan. The thinking involved in this process makes a difference in the course of action (1). Thus, neuro-anatomical and five-element perspectives likely lead to different choices of acupuncture points. I should state here that, no matter the epistemology - or how the practitioner thinks - it is still acupuncture. The issue I present here is that a shift in thinking can alter results. And, that depending on the circumstances one method of thinking may work better than another.
Use of diagnostic terms assumes ontology, which refers to categories of being. Ontology is a discussion about what is. In this case, certain assumptions are required for any medical practitioner to identify disease entities. Thus, ontology could be considered to be the assumptions that are behind the building of knowledge. In Chinese medicine, this might be the statement that chronic disease damages the network vessels (luo mai).
Presuppose the assumptions of practice: on what basis can a disease category be said to "be"? Such inquiry is culturally embedded. For Chinese medicine, the core assumption is vitalism, or qi. This vitalist point of view is often placed in stark contrast to the naive materialism that informs some scientific points of view. Such a scientific practitioner might characterize vitalism as a belief. Philosopher-scientist Bertrand Russell summarized both science and vitalism as metaphysics, that is, they are both an attempt to conceive the world as a whole through means of thought (2). Each view poses a distinct ontology. Russell achieved a comprehensive view that was inclusive of both vitalism and science.
Movements in the field of acupuncture are taking place that would eliminate traditional Chinese medical terms. The argument is that these terms are out of touch with contemporary medicine and that they are rooted in agrarian culture. The belief is that acupuncturists should be trained in the biological basis and anatomical basis of acupuncture and that the practitioner should be able to explain how acupuncture works and employ those theories in the development of treatment plans. They are right - partially - and this is where the danger lies.
Adapting the skills of western medical terms is critical to the enculturation of Chinese medicine in the West. It is the currency of medical practice. Further, if the traditionalist practitioners avoid the terms of the larger culture of medicine in which they operate, they not only marginalize themselves but also their peers. Large segments of the population may then be unable to receive Chinese medical care.
Viewpoints on inflammation might be considered, both TCM and biomedicine. If a condition involves inflammation, the lab work might show a positive C-reactive protein or an elevated sedimentation rate. This model of thought is designed for selecting from a range of conventional treatment methods that might include: non-steroidal anti-inflammatory drugs, steroids, antibiotics or chemotherapeutics. Such characterizations of pathology do not provide a logical connection to the nuanced categories of Chinese medicine.
Inquiry from a Chinese medical practitioner's point of view makes the assessment based upon history, observation, palpation and olfaction. For heat, there will likely be increased presence of redness in mucosal membranes, visible blood vessels and in the skin. The excrescences may be foul, dark and yellowed and there is thirst. The tongue may be red and the pulse hits the fingers quickly with force. The descriptions of the events lead directly to sections of the pharmacopoeia that are critical to clinical success.
Developing the treatment plan in Chinese medicine depends on defining the location, process and severity. Chinese medicine organizes its pharmacopoeia in terms of agents that dispel wind heat, clear yin deficient heat, drain damp heat, clear qi heat, clear heat and brighten eyes, and clear heat from the blood. If these categories are abandoned, then the ability to focus in terms of location, process and severity is lost, and a biomedical epistemology cannot recapture them.
Traditional medicine codes are being developed in the 11th edition of the International Classification of Disease (ICD11), making all of these discussions pertinent. Such a set of codes will require defining ontology for East Asian medicine diagnostics. This ontology will allow for taxonomy of traditional diseases and their placement into hierarchical relationships with each other.
As a matter of further explanation, the ICTM (International Classification of Traditional Medicine) is projected to become a new member of the WHO Family of International Classifications (WHO FIC) in 2014. The ICTM codes are parallel to and intersect with the ICD codes. The objective is to produce an international classification system of terms, definitions, safety and treatment properties for traditional medicine, in effect, changing the terrain for public health and population studies regarding the use of traditional medicines.
One policy maker/scientist at a recent WHO meeting in Geneva stated that there are no term standards for traditional medicine (3). This is not true. There are three for Chinese medicine. They are the WHO International Standard Terminologies on Traditional Medicine in the Western Pacific Region (4), Wiseman's Practical Dictionary (5), and the International Standard Chinese-English Basic Nomenclature of Chinese Medicine developed by the World Federation of Chinese Medicine Societies (6). Disparities between beliefs of scientists and the facts of the matter presented here demonstrate the need for this profession to be involved in the dialog.
I am going to take a strong stand here. Deleting vitalist language from the lexicon of Chinese medicine is dangerous because it eliminates critical knowledge building tools that lead to specific actions. Similarly, the attempt to live solely in the jargon of Chinese medicine is dangerous. It can potentially limit access to care for the public. Both modern scientific approaches and early Chinese scientific approaches to practice and policy are necessary.
Rather than adhere to a single view based upon beliefs, scientific or traditional, the question will be, what is the best point of view for solving a given problem? Taking sides in scientism or traditionalism tends to obscure a clear view of the problem and stagnate the necessary debate where the interested parties can arrive at a third point of view that is inclusive and productive. Such a solution can be sought through processes that are cooperative (7) and appreciative (8), this requires an open mind, open heart and open will (9). In essence, there is a need for both scientific and traditional epistemologies with corresponding language in the practice of Chinese medicine and acupuncture.
References:
Chronic pain afflicts over 20% of the adult population. Sadly, most MDs have essentially no education in treating pain, beyond offering a few toxic medications. Then they tend to steer people with pain away from those health practitioners who are trained. This puts the acupuncture community on the front lines for addressing this epidemic.
When the body is going through a stressful event, the sympathetic system is activated. This activation will help the body with a life-threatening situation. If this state is activated for prolonged periods of time, it starts to consume energy. These traumatic events that generate stressors in the autonomic nervous system (ANS) will eventually become internalized.
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One of the things that makes acupuncture so difficult to measure is that the medicine actually does contain some esoteric aspects. There have been numerous studies that demonstrate the neurochemical reasoning behind why acupuncture points stimulate the autonomic nervous system to enact change However, not all the benefits of TCM can easily be measured by randomized, controlled trials. But does that make them fundamentally and definitively untrue?
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