Ethics in the Modern Practice of Traditional Chinese Medicine (TCM)
Part I. Educational responsibilities of TCM practitioners
Principle: It is vital that persons who offer professional services in the field of TCM maintain adequate knowledge of all the relevant subjects in order to give a level of service consistent with the current state of the art.
Problem: There are a number of deficiencies in education related to TCM, especially to its application in the modern setting, which need to be rectified. Examples of these deficiencies include the following four areas.
a) In China until recent years, persons who provided Chinese medical services grew up in a culture in which basic concepts, such as yin/yang, five elements, and jing-qi-shen (essence, qi, and spirit), had a broad meaning that could be learned through education and daily experiences. By contrast, Western practitioners of TCM are usually introduced to these concepts later in life, in a didactic manner, and with a minimum of exposure to their historical and cultural significance, as well as limited description of their meaning and relevance in the medical system. Additionally, students of TCM are often given scant exposure to the ancient texts that are required reading for practitioners in Asia, and rarely presented with biographies of model medical men and scholars that can inspire deep study of the field. As a result, the fundamental concepts and original ideas that form the basis of TCM are often improperly used by today’s practitioners to the detriment of the field and, potentially, as a barrier to effective utilization of TCM.
b) Today, modern medicine, which is the standard and orthodox form of treatment, and modern science (including, but not limited to: clinical trials, laboratory studies, and the theoretical frameworks of biology and physiology) are the means of presentation of concepts and information that is expected by most patients. Insufficient training in the sciences and modern medicine, and outright prejudice against these aspects of our knowledge base expressed by some educators (particularly writers of articles and books) can lead practitioners to provide incorrect, misleading, and potentially harmful information and recommendations, as well as suboptimal treatments.
c) Teaching of TCM often focuses on conveying the ancient dogma and the assignment of properties and effects for acupuncture points and herbs without adequate attention to essential details of their practical applications. As a result, those who are licensed to practice Chinese medicine frequently do not have adequate training in key matters affecting outcomes such as herbal dosage and duration of therapy, issues of herbal safety (including the meaning of contraindications), frequency of acupuncture therapy and the recommended techniques, and true TCM concepts of how life style influences healing. As a result, practitioners may offer therapies that have little or no value even though these are provided at great expense to patients (in terms of both cost and time); further, minor results for the patient may be wrongly interpreted as being adequate.
d) The method of self-learning and in-depth pursuit of knowledge following the initial TCM training is often ignored, so that practitioners are not encouraged to vigorously pursue additional knowledge nor taught to distinguish between valuable resources and those that are deceptive and useless. There is an unfortunate abundance of intellectual dishonesty in the broad field of “alternative medicine,” a field to which TCM, as practiced in the West, often attaches itself. To quote a useful definition: “Intellectual dishonesty is the creation of misleading impressions through the use of rhetoric, logical fallacy, fraud, or misrepresented evidence. It may stem from an ulterior motive, haste, sloppiness, or external pressure to reach a certain conclusion. The unwary reader [or hearer] may be deceived as a result” (Wikipedia 2005). TCM practitioners may be led into beliefs that have little relevance to either TCM or modern medicine, and which have little or no basis anywhere, giving patients a false sense of hope and contributing to their confusion about health matters.
Resolution: It is first necessary that members of the profession become aware of these deficiencies. An obstacle to this is that a practitioner or student or even an entire school faculty may agree that such problems exist, but only somewhere else. The deficits are, in fact, widespread and to some extent affect all TCM practitioners today to varying degrees (indeed, all people face related challenges in their various professions). So, acknowledging the deficits is essential.
Once the deficits are acknowledged, practitioners must be willing to put aside a certain amount of time towards study and contemplation that will narrow the knowledge gap. This is accomplished through active and ongoing critical study by the practitioner, and should not be dependent on symposia that are utilized for continuing education credits or for attaining additional techniques or certifications. Critical study is a never ending process, because the subjects involved have a great depth and the medical situation is ever changing.
Once this time is set aside, a process of examining sources of information and ideas with good judgment must be established. The relevant materials must be accessed, studied, and then given consideration as to how they might apply to actual situations. In China, there is a concept of “cultivating” oneself, one’s moral and ethical principles, and one’s qi. This is accomplished by a three-fold process of study, living a life style that is consistent with the underlying principles, and putting the fruits of study and daily experience into practice. This ideal of self-cultivations serves as a model for the TCM practitioner.
I would like to quote briefly from a statement on ethics provided by the Taoism Culture and Information Centre (Taoism Culture and Information Centre 2006):
“Taoism [Daoism] considers ethical education and practice as its fundamental task. On the one hand, Taoism tries to publicize its theory and doctrine in society, leading people to be good in the hope of creating an ethical society. This is Taoism’s ethical education. On the other hand, Taoism encourages ethical practice, which is to lead human beings to good behaviour. Ethical practice aims at accomplishing one's duties and accumulating merits, which is to bring forth one’s spiritual release, instead of seeking to win compliments”.
I think most people will see that these principles exist, with similar form, in the Judeo-Christian tradition, in Buddhism, and, in fact, all religious and spiritual traditions. Taoism is an especially useful reference point because of its close relation to the development of TCM.
In an article I wrote on the essentials of Taoism and the Taoist influence on medical literature (Dharmananda 1997), I included this quotation from Xu Dachun (Unschuld 1990); writing about 250 years ago, on the need for physicians to continually study:
“Physicians whose training is insufficient may still avoid harming people as long as they are able to follow proper principles. And if they are able to remain modest, and if they attach great importance to studying, their knowledge will progress every day, and each of their therapies will result in a cure. Hence their fame and reputation will increase and many people will seek their help as a consequence-with riches following them. If one searches for nothing but riches, one will miss both fame and riches. Why do the physicians increase their own problems by neglecting one [studying] and going for the other [seeking rewards]?”
Gong Xin (ca 1600 A.D.) had written about the proper approach used by enlightened physicians and what is too often the actual case—the methods of common physicians—as relayed in a now out-of-print book on medical ethics in China (Unschuld 1979):
“The enlightened physicians of today cultivate humaneness and righteousness in their attitude. Their study is extensive and embraces all of the writings in their entirety. For this reason, they are well versed in theoretical medicine and its practical use. They know yin and yang, and understand the macrocosmic phases [yün] and the types of climate [qi]….They ponder over their best procedures, are flexible in their treatments, and do not cling mechanically to any formulas….Today’s common physicians’ brag about the unusual and the strange. They do not study the classic writings; neither do they understand the meaning of the words. They praise themselves into the forefront in order to deceive the world around them….they being a confused treatment without having searched for the origin of the disease....”
In quoting these writers from centuries ago, I am demonstrating that the problems of today were the problems of all times. However, today we have a somewhat organized system of college education of practitioners, so we should be getting past these problems rather than passing them on. In quoting these writings, I do not wish to put too much emphasis on the need to know yin and yang, yün and qi, or even the classical writings; there is just as much, if not more need to know the relevant aspects of modern medicine, the modern understanding of herbs, and other parts of the knowledge base that were unknown in their times. I also wish to point to the Gong’s caution about the “unusual and strange.” It is unfortunately common today for many practitioners to adopt devices and techniques that are, in relation to both TCM and modern medicine, truly “unusual and strange.”
In China, students of TCM are presented with biographies of numerous famous physicians; these biographies are not so much accurate portrayals of their lives as stories to encourage the students towards great things. In every biography, there is mention of the intensive study of the classics and the great efforts to pursue knowledge of medicine. As an example, Hua Tuo (which many practitioners know for the acupuncture points named after him) has this story, which I summarized from various Chinese sources and relayed in my article about him (Dharmananda 2002):
“Hua Tuo studied and mastered various classics, especially those related to medical and health measures, but also astronomy, geography, literature, history, and agriculture, when he was young. He was stimulated to pursue a career in medicine after seeing so many people die of epidemics, famines, and injuries from wars. His father had died when Hua Tuo was seven. His family lived in poverty and his mother wanted him to pursue a career. So, he walked hundreds of kilometres to Xuzhou to access all the medical classics retained there and learned from a famous physician named Cai. He studied tirelessly while practicing medicine, and became expert in several fields, including acupuncture, gynaecology, paediatrics, and surgery”.
Studying tirelessly is often the only way to catch-up on the needs of patients, especially when the training in TCM is so limited. Ethically, it is a requirement.
Dharmananda, S. Essentials of Taoism and the Taoist influence on Chinese medicine literature. [online]. (1997). Available from: http://www.itmonline.org/arts/taoism.htm [Accessed 15 February 2006].
Dharmananda, S. Hua Tuo. [online]. (2002). Available from: http://www.itmonline.org/arts/huatuo.htm [Accessed 15 February 2006].
Taoism Culture and Information Centre. Essential Education and Practise. [online]. (2006). Available from: http://www.eng.taoism.org.hk/daoist-beliefs/ethical-education&practise/pg2-6-intro.asp [Accessed 15 February 2006].
Unschuld, P.U. (1990). Forgotten Traditions of Ancient Chinese Medicine. Brookline: Paradigm Publications.
Unschuld, P.U. (1979). Medical Ethics in Imperial China. Berkeley: University of California Press.
Wikipedia definition. Intellectual Dishonesty. [online]. (2005). Available from: http://en.wikipedia.org/wiki/Intellectual_dishonesty [Accessed 15 February 2006].