Tuesday, April 10, 2012

Toward an Understanding of Classical Chinese Medicine

This is the first of a series of posts I hope to make over the course of a year or two on the therapeutic value of Classical Chinese Medicine. In doing so, I’m not intending to make any claims for the (comparatively superior or otherwise) therapeutic value of “holistic medicine” in general, indeed, I believe that many of the claims on its behalf by its aficionados, be they practitioners or patients, are probably exaggerated, misleading, or, quite frequently (and far worse), false. My interest in this subject is motivated by a broader concern with the sundry questions that arise among and between modern science, religious worldviews (broadly construed), and what we’ll term the “healing arts.” I’m particularly intrigued by the philosophical and religious underpinnings—beliefs, values, orientations—that “justify” or influence these arts. And to narrow the focus even further, it is religious worldviews of Asian provenance that intrigue me most of all, although for the time being we’ll attend to those of primarily Chinese pedigree.

In the following, I aim to sketch some epistemically sound reasons for a cross-cultural appreciation, understanding, and possible evaluation of what is termed Traditional Chinese Medicine (hereafter TCM) but, for reasons to be explained later, is better called Classical Chinese Medicine (hereafter CCM). I share with most readers a lack of disciplinary expertise on this subject, approaching it as a curious and inspired amateur, an educated layperson utterly dependent, in the end, on those in possession of the requisite professional and practitioner’s knowledge (and skill), a knowledge often assiduously nurtured over the better part of a lifetime. Perhaps the lack of expertise can be compensated by an ardent avocational interest, recalling with John Ziman (2000) that “Until…the middle of the nineteenth century, almost all scientists were amateurs” (49). What professional training I do possess relevant to our topic concerns the cross-cultural study of worldviews, a field of inquiry fundamental to an appreciation of CCM in a way that takes us in several respects us beyond the sieve of biomedicine. And I doubt we can sufficiently appreciate many of the relevant differences between Western biomedicine and CCM without some sort of minimal understanding of the worldviews from which the philosophical and doctrinal foundations of CCM emerged and its subsequent theory and therapeutic praxis has flourished. To the extent that we succeed in our preliminary investigations, we will come to understand several reasons why CCM is rightly placed under the rubric of “complementary” medicine in a manner that resists complete incorporation or subsumption within Western biomedicine while nonetheless possessing scientific stature that rightly belongs to effective therapeutic modalities. At the same time, we should also come to see why there is no compelling reason why we should characterize CCM as an “alternative” medicine in the sense that this implies a disavowal of the very real therapeutic benefits brought to us by biomedicine. As Grant Gillet has written in Bioethics in the Clinic: Hippocratic Reflections (2004), there is no need to undermine the “purpose-driven cognitive maps of a domain of praxis” found in biomedical knowledge in “permit[ting] alternative conceptualizations where the phenomena covered are complex and may be produced by the interaction of multiple factors” (61). I’m assuming that not all of the therapeutic benefits generated by CCM can be chalked up to placebo effects, such effects only now being studied in the thorough and rigorous fashion (see Brody 1980; Evans 2004; Harrington 1999; Kolber 2007; and Moerman 2002) they warrant. Nonetheless, even if it turns out that at least some of the therapeutic benefits attributed to CCM can be chalked up to placebo effects, this should not speak against our main contention, namely, that Chinese medical doctrine and therapeutic praxis should be seen as belonging within the larger corpus of scientifically respectable and medically effective therapeutic modalities.

Testimonial Reports and Presumptive Knowledge
In the West, the first exposure to Chinese medicine typically takes the form of acupuncture, and is probably motivated in the first instance under the epistemological heading of (favorable) anecdotal or testimonial reports, the sort of evidence routinely dismissed or derided in philosophical and scientific circles, and frequently for good reason. A serendipitous illustration from a deservedly popular book used in courses on critical thinking and informal logic will suffice:

“if you are deciding whether or not acupuncture is an adequate alternative to conventional medicine, someone might tell you that their friend tried acupuncture and that it seemed to work wonders. On its own this is merely anecdotal evidence. First, there is a risk that details of the story may get changed in the retelling. More importantly, to argue from this simple case that acupuncture is an adequate alternative to conventional medicine would be irresponsible: anecdotal evidence is different from a controlled scientific investigation into the effectiveness of acupuncture.” (Warburton 2000: 15-16)

Of course evidence-based medicine (EBM) enthusiasts are reflexively nodding in agreement, and understandably so. But let’s complicate matters a bit. Warburton goes on to remind us that “not all anecdotal evidence is unreliable: if you have reason to be confident in the source of the evidence, then anecdotal evidence can help to support or undermine a conclusion’’ (16). In fact, I suspect very few people argue in the “irresponsible” manner of our hypothetical example. Indeed, further vindication for some kinds of anecdotal evidence follows the realization that “many sorts of scientific enquiry begin by examining anecdotal evidence about the phenomenon to be examined” (16).

There are other reasons we might hold for valuing anecdotal evidence or “testimonial reports.” For instance, we might, with Alvin Goldman (1999), appreciate the societal distribution and frequency of anecdotal reports in public fora outside disciplinary domains or intellectual fields of expertise insofar as they facilitate the spread of knowledge: “Communication [used here in the sense of sharing discovered facts] is an efficient mode of increasing knowledge because information transmission is typically easier, quicker, and less costly than fresh discovery. [….] Since not every member of a community observes each fact other members observe, there is room for veritistic [i.e., ‘truth-linked’] improvement through communication” (Goldman, 1999: 103). The assumption here is that testimonial reports or observations are accurate or true, but of course false anecdotal or testimonial reports occur for any number of reasons:

“False reports can issue from observational error. A second source of inaccurate testimony is dishonesty or insincerity, which can be prompted by a variety of incentives the speaker might have for deception. Similar incentives can lead a potential informant to prefer silence to either disclosure or mendacity. In fact, it is not obvious what generally motivates knowledgeable agents to disseminate their knowledge. The conveyance of information, it appears, generally profits the receiver rather than the communicator.” (106)

As non-experts, most of us at any given time are in the role of either “receiver” or “communicator,” a fact that may help motivate us when it comes our turn to be in the role of communicator, so while the conveyance of information “generally profits the receiver rather than the communicator,” that fact need not long deter us in the search for sufficient motivation or incentive for informed agents to disseminate knowledge. Nonetheless, Goldman explains why we might come to see anecdotal evidence or testimony as trustworthy in the first instance, as something we generally take for granted when it comes to the increase of true beliefs (‘veritistic improvement’). Thus the accuracy of reporters’ observations, of testimonial reports, can serve as a default presumption, the exceptions serving to entrench the rule. Goldman reminds us that the view that “people have a [natural] default disposition to speak the truth, to express their beliefs honestly and sincerely,” was well expressed in the Scottish philosopher Thomas Reid’s “motivation-innateness” hypothesis (106). And although we know from personal experience that an “innate disposition toward truthful revelation can be overridden by conflicting incentives,” social mechanisms as crude as reward and punishment, by way of firmly established social norms, for example, can motivate potential speakers to increase their capacity for veritistic improvement of knowledge communication (106-107). In addition to Reid’s hypothesis handed down from the Scottish Enlightenment, Goldman provides us with a handful of non-reductionist epistemic theories of testimonial justification found in contemporary epistemology, noting “Philosophers have been struck by how many of our beliefs are based on testimony, where it is doubtful that there is any testimony-free basis for trusting that testimony” (126). It seems we can make some progress toward exorcising dispositional skepticism toward the theory and practice of CCM, knowledge of the therapeutic benefits of which is often communicated anecdotally, in testimonial reports.

Yet another (and not unrelated) way to meet initial skepticism or epistemically motivated doubts about the efficacy of therapeutic practices and doctrinal ideas from Chinese medicine is to see the latter as taking the form of presumptive knowledge, as possessing tentative plausibility (largely pre-evidential in bearing from the perspective of EBM; I’m well aware there exists some scientific evidence for the efficacy of acupuncture as summarized, for example, in the NIH Consensus Statement on Acupuncture): “The key idea of presumption thus roots in analogy with the legal principle: innocent until proven guilty. A presumption is a thesis that is provisionally appropriate—one which can be maintained pro tem, viewed as applicable until or unless sufficiently weighty counter-considerations arise to displace it. On this basis, a presumption is a contention that remains in place until something better comes along” (Rescher 2003: 85). Presumptions have significant probative weight but are in principle defeasible, that is, ”subject to defeat in being overthrown by sufficiently weighty countervailing considerations” or by “something more evidentially substantial.” This is in keeping with the contemporary epistemologist’s conception of knowledge in general, which is “fallibilist,” meaning the possibility of error can never be logically eliminated. Moreover, “not everything qualifies as a presumption: the concept is to have some probative bite. A presumption is not merely something that is ‘possibly true,’ or that is ‘true for all I know about the matter.’ To class a proposition as a presumption is to take a definite and committed position with respect to it, so as to say, ‘I propose to accept it as true insofar as no difficulties arise from doing so’” (Rescher 2003: 92). Michael Williams (2001) likewise informs us that the presumptive “justification” of personal beliefs within a fallibilist epistemology takes the form of “what Robert Brandom calls a ‘default and challenge’ structure: entitlement to one’s beliefs is the default position; but entitlement is always vulnerable to undermining by evidence that one’s epistemic performance is not up to par” (25).

Rescher argues that there is a (default epistemic) “presumption in favor of such cognitive sources as the senses and memory—or for that matter trustworthy personal or documentary resources such as experts and encyclopedias” (Rescher 2003: 96). Williams (2001) puts it this way: “In claiming knowledge, I commit myself to my belief’s being adequately grounded—formed by a reliable method—but not to my having already established its well-groundedness” (149). It therefore seems safe to conclude that our cognitive affairs are such that we commonly and routinely incorporate a host of fundamental presumptions of reliability, for example, and again, accepting at face value the declarations—testimony—of other people and, after Rescher, the declarations of recognized experts and authorities within their respective domains of expertise. For our purposes, the latter entail the (sometimes ‘sacred’) texts of CCM transmitted from one generation to the next by its various practitioners who transmit their knowledge and expertise in “secret,” through “personal” and “standardized” modes of transmission (cf. Hsu 1999; Lloyd and Sivin, 2002). Inasmuch as plausibility is, for Rescher, one of the criteria for evaluating presumptions, we are caught in a virtuous epistemic circle, for “the standing of an authoritative source is an important criterion of plausibility” (Godden and Walton 2007: 326). Williams (2001) reiterates this point in a way palatable to the epistemological views of both Goldman and Rescher: “The social distribution of reason-giving abilities allows us to inherit knowledge by deference to experts. In a complicated society, an enormous amount of knowledge is acquired this way” (154). This in turn enables us to appreciate precisely why, for the individual, “being [epistemically] justified is not always a matter of having gone through a process of justification” (154). That we are dealing with Chinese medical texts and Chinese experts hardly seems sufficient reason to deny them the presumptive deference we accord to the opinions and judgments of other, more familiar (i.e., ‘Western’), expert authorities. At the very least, we can concede the Chinese (and anyone socialized into its traditions) have a host of sufficient presumptive reasons for deference to CCM, reasons others outside of Asia might likewise see fit to entertain in an identical manner. In other words, “Respect duly established expertise” (Goldman 1999: 372), although one might bear in mind recent “advances” in biotechnology and psychopharmacology when heeding Goldman’s reason for

“why the public should reserve a healthy dose of skepticism for the new ideas of researchers and practitioners in a field—any field…. Researchers and practitioners have a built-in incentive to promulgate their own innovations: innovation is what earns them kudos and recognition [and in the case of biotechnology and psychopharmacology, lots of money]. The ‘tired and true’ does not attract much attention. Researchers and practitioners want to show the public that they can make advances in their field, and are therefore prone to exaggerated the promise or proven effectiveness of their new ideas and methods.”(372)

In short, we’re entitled to a belief in the veritistic value of CCM until such time as we are provided with sufficiently weighty countervailing epistemic evidence. And our willingness to entertain the epistemic value of CCM could said to be enhanced to the extent we’re also willing to exercise a corresponding caution (or simply less naïveté) about the putative groundbreaking “advances” in and products of biotechnology and psychopharmacology. A measure of skepticism is reasonable on this score if we consider the invariable halo effects of Western science and high technology together with the powerful socio-economic forces that fuel the commercialization and marketing mania that increasingly define the nature of “privatized American science” (Angell 2011; Mirowski 2011). Michael H. Cohen tells us a story about his attendance at an international congress on Tibetan Medicine in 1998 in which the Dalai Lama “reflected on the hubris and ethnocentrism often described as embedded in modern scientific efforts within the Western Hemisphere to understand indigenous and other medical traditions.” This includes an inability to see beyond the presuppositions and assumptions that make up the marrow of the scientific models of modern medicine in the West (and now around the globe) and thus are essential to its dramatic success on many fronts (Thagard 1999). So, for example, Cohen notes that “even when open to exploring other medical systems,” clinicians and research scientists beholden to these models seem constitutionally unable to appreciate the “role of consciousness in mediating healing therapies, [and] tend to imagine that the medical system adopted relatively recently in human history” possesses a monopoly of privilege and a patent on authority by which to “filter, understand, and synthesize other medical traditions” (Cohen 2006: 1-2). It is for this reason I will refer to the medical significance of CCM (and, at a later date, other complementary and alternative medicines or CAMs) as “beyond the sieve of biomedicine.”

References & Further Reading:
  • Angell, Marcia. “The Epidemic of Mental Illness: Why?,” The New York Review of Books, June 23, 2011.
  • Angell, Marcia. “The Illusions of Psychiatry,” The New York Review of Books, July 14, 2011.
  • Brody, Howard. Placebos and the Philosophy of Medicine: Clinical, Conceptual, and Ethical Issues. Chicago, IL: University of Chicago Press, 1980.
  • Cohen, Michael H. Healing at the Borderland of Medicine and Religion. Chapel Hill, NC: University of North Carolina Press, 2006.
  • Evans, Dylan. Placebo: Mind over Matter in Modern Medicine. New York: Oxford University Press, 2004.
  • Farquhar, Judith. Knowing Practice: The Clinical Encounter of Chinese Medicine. Boulder, CO: Westview Press, 1994.
  • Gillet, Grant. Bioethics in the Clinic: Hippocratic Reflections. Baltimore, MD: Johns Hopkins University Press, 2004.
  • Goldman, Alvin I. Knowledge in a Social World. New York: Oxford University Press, 1999.
  • Godden, David M. and Douglas Walton. “A Theory of Presumption for Everyday Argumentation,” Pragmatics & Cognition 15: 2 (2007): 313-346.
  • Harrington, Anne, ed. The Placebo Effect: An Interdisciplinary Exploration. Cambridge, MA: Harvard University Press, 1999.
  • Hsu, Elisabeth. The Transmission of Chinese Medicine. Cambridge, UK: Cambridge University Press, 1999.
  • Hsu, Elisabeth, ed. Innovation in Chinese Medicine.Cambridge, UK: Cambridge University Press, 2001.
  • Kaptchuk, Ted J. The Web That Has No Weaver: Understanding Chinese Medicine. Chicago, IL: Contemporary Books, 2nd ed., 2000.
  • Kolber, Adam J. “A Limited Defense of Clinical Placebo Deception,” Yale Law & Policy Review, Vol. 26, 2007; San Diego Legal Studies Paper No. 07-87. Available at SSRN: http://ssrn.com/abstract=967563.
  • Kuriyama, Shigehisa. The Expressiveness of the Body and the Divergence of Greek and Chinese Medicine. New York: Zone Books, 1999.
  • Lloyd, Geoffrey and Nathan Sivin. The Way and the Word: Science and Medicine in Early China and Greece. New Haven, CT: Yale University Press, 2002.
  • Maciocia, Giovanni. The Foundations of Chinese Medicine. Edinburgh: Churchill Livingstone, 1989.
  • Mirowski, Philip. Science-Mart: Privatizing American Science. Cambridge, MA: Harvard University Press, 2011.
  • Moerman, Daniel E. Meaning, Medicine, and the “Placebo Effect. Cambridge, UK: Cambridge University Press, 2002.
  • Rescher, Nicholas. Epistemology: An Introduction to the Theory of Knowledge. Albany, NY: State University of New York Press, 2003.
  • Thagard, Paul. How Scientists Explain Disease. Princeton, NJ: Princeton University Press, 1999.
  • Unschuld, Paul U. Medicine in China: A History of Ideas. Berkeley, CA: University of California Press, 1988.
  • Warburton, Nigel. Thinking from A to Z. London: Routledge, 2nd ed., 1998.
  • Williams, Michael. Problems of Knowledge: A Critical Introduction to Epistemology. New York: Oxford University Press, 2001.
  • Zhang, Yanhua. Transforming Emotions with Chinese Medicine: An Ethnographic Account from Contemporary China. Albany, NY: State University of New York Press, 2007.
  • Ziman, John. Real Science: What It Is, What It Means. Cambridge, UK: Cambridge University Press, 2000.


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