And Evidence-Based Medicine:
A Philosophical Critique
Michael T. Greenwood, MD (MB)
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.
Acupuncture, Evidence-Based Medicine, Objectivity, Subjectivity, Relational
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 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
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
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)
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
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.
Methods of Knowledge Acquisition
How knowledge is acquired is a topic rarely mentioned in medical journals,
possibly because the theory of the double-blind trial as gold standard
is so widely accepted. But it is enlightening to consider what different
philosophers have to say about it. Oschman points out that all systems
of acquiring data are highly subjective:
we determine to be true depends on the qualitative decisions and on
the context in which they are made. It is now agreed by the leading
philosophers and historians of science (Bateson, Feyerabend, Kuhn,
Lakatos, Popper, Toulmin) that all data are theory, method, and measurement
dependent. All facts are inescapably predetermined by the theories
and methods that generate their collection." 10
of several forms of data collection which he classifies as Leibnizian
(deductive), Lockean (inductive), Kantian (synthetic), Hegelian (antagonistic),
and Singerian (relational). It has been said that Western medicine is
deductive while Oriental medicine is inductive, which is why the 2 systems
can complement each other.11 In summary, synthetic or deductive/inductive
approaches form the basis of modern scientific inquiry, antagonistic
models form the basis of politics, law, and medical research interpretation,
while relational enquiry probably forms the best model for understanding
complex multifactorial problems such as illness and the clinical encounter
|Table 1. Forms of Enquiry
||Guarantee of Validity
||Truth is arrived at through analytical deduction
||Validity is achieved through precise agreement on the proof
||Useful for mental problems - math, physics, etc.
||Good for well-structured problemsthat can be analyzed
||Increasingly inaccurateas problems becomemore complex
||Truth is arrived at through experience
||Validity is established through consensus of "experts"
||Useful for well-structured controllable situations
in which there is widespread agreement as to the nature and definition
of the problem
||Experiential data can be misleading and experts can
||Truth is arrived at through combination of theory
||Validity is achieved through a match between theory
||Useful for problems that are complex enough that
a variety of explanations can be tested
||Ability to consideralternativeperspectives
||Inherently difficult, imprecise, andtime-consuming
||Truth is arrived at through conflict and interpretation
||Validity is achieved through conflict that exposes
||Useful for complex or poorly structured problems
where there is no agreement
||Shows that the samedata can supportopposing perspectives
||Expensive if appliedinappropriately tosimple problems
||Truth arises out of relationship
||Validity tends to change with context and perspective
||Recognizes that truth is generally an approximation
||Includes anethical dimension
||Complexity and potential expense
A category error arises when an inappropriate enquiry system is used
to address a particular situation. For example, Hegelian/antagonistic
thought would be an inappropriate method to study a mathematical problem.
Similarly, interactive therapies such as acupuncture, massage, and manipulation
are interactive relational systems and are best approached by exploring
the nature of relationship. To apply an objective enquiry system to
acupuncture constitutes a category error. At
best, it wrongly reduces acupuncture to a technical procedure while
ignoring its philosophical spirit. Such reductionism is generally acknowledged
by researchers as being unfortunate but necessary. Few seem to appreciate
that it is incorrect. Category errors lead to irrelevancies such as:
solutions to the wrong problems. For example, spending copious amounts
of money on disease prevention interventions such as hormone replacement
therapy (HRT) studies, mammography, and cholesterol-lowering, when
the root issue may be existential anxiety or concerns about the
future. The author's belief is that such worry is an energetic imbalance
and should be addressed as such.
irrelevant and unimportant problems simply because they fit the
mode of enquiry. For example, treating mild hypertension because
it is measurable, while overlooking the fact that labeling people
unnecessarily with hypertension perhaps encourages illness behavior.12
Or trying to find a drug to treat the common cold when there are
more important issues.13
are rejected when they are correct. For example, many acupuncture
practitioners realize that acupuncture works increasingly well the
more their approach uses theories based in energetic or meridian
analysis. Yet respectable journals continue to publish research
studies that conclude acupuncture does not work, based on studies
that reject the theories that generate successful outcomes. Such
studies are rooted in category errors.14,15
are accepted when they are incorrect. For example, the infectious
model of disease causation becomes suspect when viewed from an acupuncture
perspective, which may convincingly demonstrate that even obvious
infections are a material reflection of a predisposing energetic
configuration. Conversely, infections are actually second-order
phenomena, the primary phenomenon being the patient's constitutional
state. While no one would deny the existence of bacteria and viruses,
most physicians would agree that the infectious model is overemphasized.
As a culture, perhaps we embrace the germ theory not because it
is necessarily true, but because it is convenient. The theory simultaneously
provides (1) a simple explanation for symptoms that patients generally
accept without lengthy, time-consuming explanations, (2) absolves
patients of personal responsibility for their illness, and (3) absolves
the physician from confronting the patient concerning personal responsibility.
It is generally assumed that there is no subjectivity in objectivity.
Conceivably, the objective perspective is actually a subjective stance,
a point of view that leads to certain ways of interpreting experience.
Such a stance in no way removes the subjective but denies it, driving
it into the unconscious where its impact is actually magnified by the
fact that it lies unacknowledged. Many psychologists believe that this
is the same process underlying many illnesses. Subjective influences
in purported objective research are then realized.
The Placebo Effect
Objective research usually includes a placebo arm to demonstrate that
the tested therapy is superior to no intervention. Implicit in such
studies is the idea that the placebo effect does not constitute real
medicine, and that only medicine that is better than placebo is "real."
Yet the placebo group often demonstrates a 30%-35% positive response
(indeed, sometimes as high as 70%),16 which implies that many people
somehow heal themselves without medicine. That they might have been
deceived into healing themselves is irrelevant. An irrational dismissal
of the potential of self-healing occurs when such healing is rejected
because no overt outer action was taken. Such a position is not only
subjective, but also ethically questionable because it robs patients
of their personal power.
Objective trials are not inclusive. Consequently, the decisions regarding
subject matter, study design, and outcome criteria are limited to researcher
interests, necessarily subjective and defined by organizational needs.
Conclusions from such research are provisional and many times wrong.
Weak conclusions would not be problematic if not translated into clinical
guidelines, often the end result, however. Sometimes, this constraint
only comes to light many years later, after a regimen has become standard
and widely used. For example, several current randomized trials on postmenopausal
HRT supplementation reveal an increased incidence of heart disease in
treatment groups.17 Apparently, the earlier HRT trials that purported
to show a decrease in heart disease did not surmise that women in the
treatment groups were healthier and more motivated than those who took
placebo. Commenting on these ongoing trials and their implications,
Deborah Grady (University of California) states: "Even the best
observational studies can give the wrong answer if there are unmeasured
differences between groups of women being compared."18 It was many
years before someone pointed out this limitation, and in the meantime,
millions of women have taken HRT in the mistaken belief that it would
benefit their heart. Moreover, this issue will not abscond with more
trials since it is an inherent weakness of this method of collecting
The reality of economics dictates that drug trials may be performed
more for financial reasons than for altruism or compassion, depending
on the researcher/funding agency's motives. For example, the motivation
behind studying such conditions as the common cold is the desire to
market a profitable antiviral, lipid research for the marketing
of lipid regulators, and peptic ulcer research for the marketing of
proton-pump inhibitors, etc. Unless profitable, research is often not
Funding is a factor. Researchers are often aware of the double bind
of commercially sponsored trials, where there is the conflict between
pleasing funding sources vs the desire for good research. Since this
seems to be an unsolvable paradox, researchers often ignore this difficulty
and hope for optimumresults. Awareness of the double bind situation
does not prevent the subjective tilt. Dependence on funding may subliminally
influence researchers to bias their results and interpretations, leading
to the release of apparently promising drugs that can be less useful
once in general circulation,19 e.g., the furor associated with some
of the calcium channel blockers.20 External pressure can be unpleasant.
One well-publicized case involved a researcher who faced a lawsuit from
the sponsoring drug company when she attempted to
publish unfavorable results on an experimental drug for thalassemia.21
Regarding interpretation, the same subjective bias continues. Since
objective studies frequently generate equivocal results, they often
generate more questions than answers, and lead to repeated studies in
a never-ending attempt to prove something acceptable to various interest
groups. This leads to increasing complexity, which leads to the need
for interpretation, which then leads to differing opinions from different
interpreters. For example, many researchers have wondered whether the
pressure for mammography screening was motivated by political and economic
interests rather than science.22 In this way, Hegelian analysis appears
as different authorities argue over details of the interpretation. Since
hermeneutics is usually based on personal opinion, it is by necessity
highly subjective. Thus, subjectivity becomes the final arbiter of what
is supposedly objective.
Objective studies only appear to be objective within a widely accepted
context. When a program or therapy impinges from outside the familiar
contextual base, it is often not accorded the same respect, resulting
in a double standard of acceptability to medical practice. Many of the
difficulties encountered in trying to integrate acupuncture and herbal
remedies into mainstream medicine arise from this kind of double standard.
Because alternative approaches have a different philosophical foundation,
they are often automatically viewed with suspicion. Double standards
are highly subjective since they arise out of prejudice and not from
objective science. Yet a pretense of objectivity is often used to justify
the imposition of rules and regulations arising out of such prejudice.
A case in point is the recent ban on formulas
containing Trichosanthes kirilowii seed (gua lou zi), Magnolia officinalis
root bark (hou po), and Fritillaria thunbergii bulb (zhe bei mu) by
Health Canada despite the fact that compared with most drugs and in
the doses commonly used, these herbs are harmless.23Apparently, no one
involved in the decision-making process was aware of the most basic
principles of herbology, and the decision was made in the absence of
a single complaint or report of an adverse effect. Such regulatory forcefulness
seems illogical when one considers the massive impact of iatrogenic
sequelae from drugs.24 Meanwhile, dangerous drugs continue to slip through
the screening process, sometimes approved too hastily by FDA scientists
under pressure from pharmaceutical companies that many times provide
much of the FDA's funding, e.g., the FDA's speedy approval of the irritable
bowel syndrome drug, alosetron (Lotronex), in February 2000. The drug
was hastily withdrawn in November 2000 after the deaths of 5 people
and hospitalization of another 34 people.25 Maybe when objective studies
are motivated by economics, interpretation is biased in favor of self-interest
groups and double standards are applied to innovative treatment options.
Perhaps there is a paradigm shift under way that has nothing to do with
the emergence of EBM. Rather, it is concerned with a transformation/transcendence
of the dualistic assumptions on which all objective medicine is based.
Western science has been characterized by reductionism, linearity, and
causality.26 Yet these are all manifestations of a deeper dualistic
principle in which the mind, separating itself from direct experience,
seeks explanations for what it observes. Whatever the ego favors is
deemed acceptable. Conversely, experiences that the ego finds objectionable
become problems to be solved, and the principle of cause and effect
is engaged to elucidate a mechanism that might be amenable to some tampering.
In medicine, this manifests itself as "diagnosis and treatment."
We imagine that where there is an effect, there must be a cause. A disease
is presumed to be an effect of some prior cause, and a cure is sought
by interfering with the mechanism of production of the effect. One obvious
difficulty with this particular thinking is that there is no end to
the cause and effect chain. For whatever chosen present cause, there
must always be a prior cause from which the present cause arises.
Cause and effect is a deterministic approximation that provides a shallow
understanding of that which is actually a profound mystery. In reality,
there is no specific cause for anything because all phenomena are interdependent.
As for approximations, the principle works well in many circumstances,
particularly for acute situations; conceivably, the reason it has been
so widely adopted. But in complex multifactorial situations, such thinking
overlooks the fact that all the individual
components of complex systems contribute to the behavior of all the
other components. Perhaps one cannot actually say that there is a specific
cause for a body manifesting a particular symptom complex.
This leaves rational medicine with a fascinating conundrum. If everything
is interconnected, then one can say: an illness is as it is because
the individual is as he or she is. While such a statement makes no sense
in terms of cause and effect, it is actually a more accurate description
of the dilemma. However, it demands that we find a premise other than
cause and effect through which we might better understand complex interdependent
systems. One possibility borrowed from quantum physics is a concept
termed "relational holism;" similar to Jung's notion of synchronicity,
it attempts to conceptualize the overall effect of instantaneous non-linear
interconnections between system components.27 The end result is that
people, similar to subatomic particles, are actually not separate units
and can never be considered in isolation from the whole of which they
are a part.
An acceptance of the inappropriateness of cause and effect demolishes
the sanctity of diagnosis in complex multifactorial illness, a cornerstone
of conventional medical practice and EBM. Physicians are admonished
to make accurate diagnoses before initiating treatment, with the argument
that an accurate diagnosis makes for good science and rational treatment.
Yet the reality is that in chronic multifactorial illness, an accurate
diagnosis is not always possible, an obvious fact to anyone working
in primary care. But rather than questioning the model, physicians perhaps
disguise ignorance with seemingly erudite phrases that sound like diagnoses
to the uninitiated, but which are only statements of syndromes or what
might be called "translations of symptoms into medical jargon."
For example, unremitting pain becomes reflex sympathetic dystrophy,
aching and fatigue become fibromyalgia, while rigidity and tremor become
Parkinson's disease. Patients may believe that we are voicing profound
insights into their conditions when often we are not. We are merely
putting labels on syndromes, not making definitive diagnoses.28,29 For
instance, if a study is conducted to study fibromyalgia, researchers
often fail to remember that fibromyalgia is not actually a diagnosis.
Rather, it is a syndrome, a cluster of symptoms for which there is as
yet no coherent explanation. To pretend there is a diagnosis is clearly
subjective and has no particular justification other than convenience.
Yet much research is done from this position. Conclusions arising from
such research are often meaningless since the diagnosis itself is meaningless.
The Loss of Meaning
Conceivably, the main difficulty with all dualistic concepts such as
cause and effect, diagnosis and treatment, or problem and solution is
that while they can sometimes elucidate mechanism, they can never elucidate
the root. The root necessarily lies in a different order of reality
and is actually the organizational principle that maintains the configuration
and is transcendent to it. When it applies to the human body, this principle
might be regarded as soul, or in acupuncture terms, the Tao. Either
way, consideration of the root plunges the researcher/clinician into
areas habitually shunned by modern medicine, areas normally relegated
to philosophy or religion.
Despite modern medicine's wish to deny such deeper principles, as physician-acupuncturists,
we cannot engage in the same kind of denial without compromising the
basic principles on which acupuncture rests. I have previously discussed
the principle of intent, and how Oriental medicine understands illness
as arising from the sense of separation from the Tao, which occurs progressively
as the ego develops.30 The implication of such considerations is that
an illness is not a
separate entity to be rooted out like an alien invader as the cause
and effect model would suggest. Rather, symptoms are pointers to repressed
energetic material that, for one reason or another, have not been allowed
full expression. In summary, an illness represents a materialization
of everything an individual energetically needs to rediscover his/her
EBM rarely considers concepts of meaning because such considerations
are philosophical and contradict the mechanistic paradigm. But, when
researchers assume that amelioration of symptoms is an appropriate end
point, and medicine uses such evidence in its guidelines, then a confusion
of treatment and healing arises. Treatment constitutes interference
with the mechanism of production of symptoms, while healing demands
that the individual listen to, heed, and somehow integrate the message
contained in the symptoms. Thus, EBM confuses "shooting the messenger"
with healing, a confusion that has permeated the entire medical system.
This is a profound error, and one that Groddeck warned against. Once
this point is realized, it becomes clear that any conclusion arising
out of objective science, and any EBM guidelines affiliated with such
research, are going to be largely irrelevant to energy medicine.
The Existential Split
A philosophical consideration of problem-oriented thinking will reveal
its origin to lie in a sense of alienation coming from the primary existential
split.31 To briefly summarize, the existential split leads to thinking
erroneously that humans are separate and alienated beings, somehow divorced
from the whole. Since the primary split is actually a mistaken intellectual
perception, the sense of alienation that manifests as problem-oriented
thinking is actually an illusion. The difficulty is this: if there is
no split, then there can be no problem, and so the question of how to
solve a particular problem becomes meaningless.
Thus, beyond the existential split, there can be no objective defense
behind which the researcher or clinician can hide. After all, what makes
the definer of a problem think he/she lies outside the boundaries of
his/her own definition? That might appear a foolish question, but from
a holistic point of view, it is impossible for the researcher, practitioner,
or patient to lie outside anything because there is no boundary and
no outside. The point then is that whoever defines a problem are themselves
the problem because the idea of their being a problem is really a product
of the their own imagination, which is rooted in an erroneous assumption
of dualism. For this reason, researchers should not pretend that they
are outside the boundaries of a problem they have defined. Similarly,
patients should not pretend they are not responsible for their illnesses,
and clinicians should not assume that illnesses are problems and then
habitually prescribe medications/modalities designed to interfere with
the mechanism of production of symptoms.
The actual emerging paradigm reflects a shift toward a non-dual understanding
of illness and health in which problem-oriented thinking is transcended.
A holistic viewpoint, for example, does not consider illnesses a problem
at all but rather a natural and inevitable part of the whole. From this
perspective, the job of healing involves experientially integrating
the symptom energies into a more optimal configuration, not manipulating
or trying to eradicate them. This has massive relevance when it relates
to acupuncture, which has a non-dual philosophical base in the Tao.
To ignore the implications of non-duality to make acupuncture conform
to dualistic research protocols is not acceptable. Since all research
is by definition dualistic, its conclusions are only valid within the
confines of dualistic thinking. Therefore, such conclusions cannot be
applied to acupuncture or any other interactive therapy without committing
a category error.
Relational holism considers the context of illness to have as much,
if not more, validity than the specific diagnosis because energetically,
diagnosis in any conventional sense does not exist. The energy field
has a certain pattern of harmony or disharmony within it. Pattern recognition
can be helpful, but it is not the same as a conventional diagnosis.
Nor is it ever considered totally accurate; room for subjective uncertainty
exists. Contextual analysis dispenses with the illusion that diseases
exist as discrete entities that can be studied in isolation, such as
breast cancer, depression, or epilepsy. In reality, a disease exists
only in the context of the person who has it, who in turn exists in
the context of a particular family, society, environment, etc. Indeed,
a disease is actually defined by the context in which it arises. Without
a context, there is actually no disease because there is no one to whom
it is happening.
It is becoming increasingly clear that researchers cannot disregard
context and retain any semblance of the original situation. Similar
to taking an egg and scrambling it and then pretending the original
structure is still there, the folly of reductionism lies in the pretense
that conclusions arising out of approximations have validity. When researchers
reduce and approximate, the essential wholeness is lost and the original
entity being studied no longer exists. This leaves all clinical protocols
arising out of objective research meaningless; in the end, being eliminated
by the Tao. Therefore, in silent deference to the Tao, the astute practitioner
moves beyond protocol and embraces the subjective reality of an interaction,
allowing a solution to present itself out of the relational dynamics.
To be sure, he/she brings objective knowledge to the interaction but
refuses to give it first place. If that seems unreasonable, notable
is that even the gurus of EBM concede the point when pressed. In the
words of Sackett et al:
doctors use both individual clinical expertise and the best available
external evidence, and neither alone is enough. Without clinical expertise,
practice risks becoming tyrannized by evidence, for even excellent
external evidence may be inapplicable to or inappropriate for an individual
Science of Relationship
Since the non-dual stance is not problem-oriented, a practitioner who
acts holistically perhaps encourages the spontaneous emergence of solutions
through the transformational dynamics inherent in relationship. Bringing
the insights of quantum physics into medicine demands a different set
of assumptions from traditional science, including an acceptance of
mystery, a transcendence of the objective/subjective dichotomy, and
an intent to move toward the symptom complex. These concepts are not
new, but are sensible descriptors of a good healing relationship. If
medical science understood such principles, the frenetic search for
rational treatment programs would give way to a rediscovery of the value
of a physician's compassionate presence. Some of the factors involved
in such a relationship are addressed in Table 2.
Table 2. Some Factors Involved in a Relational Science
- Illness is largely a subjective experience
- Objective knowledge is not the final arbiter
- Healing always involves an element of mystery
- The patient is his/her own cause and cure
- The illness itself contains all the necessary information
- Intention should be to move toward symptoms
- The practitioner's role is to listen and teach, but not to
- Confidentiality should be absolute
Physician-acupuncturists are called to perform the impossible task of
paying heed to the guidelines put forward by EBM, while simultaneously
trying to engender a healing intent in patients even though those 2
processes are contradictory. Thus, many of us perceive ourselves in
a classic double bind. If we follow rational guidelines implicitly,
may be embracing symptom suppression; if we follow the implications
of a non-dual world view, we appear to reject objective evidence-based
Such a conundrum could be daunting were it not for the fact that patients
with chronic illness face precisely the same conundrum, a double bind
from which there is no logical or rational escape. Thus, to help people
transcend their rational minds to solve the mystery of chronic illness,
we are simultaneously forced to transcend the limits of our own rational
approach to illness. Perhaps it would be less complicated if scientific
medicine were to recognize its own limitations and not stray into areas
where the application of objective principles is inappropriate. The
responsibility lies with each practitioner to find his/her own solution
to the contradiction.
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Dr Michael Greenwood is the Medical Director of the Victoria Pain Clinic,
a residential facility in Victoria, British Columbia, Canada. Dr Greenwood
specializes in working with chronic pain and illness patients, and in
developing techniques integrating the body, mind, and spirit. He has
authored the books, Paradox and Healing, and Braving the Void.
Michael T. Greenwood, MB (MD), BChir, CCFP, CAFCI, FRSA
Victoria Pain Clinic
365 Hector Road., RR#3
Victoria, British Columbia V9E 2C3 Canada
Phone/Fax: 250-595-1486 Email: email@example.com