Letter to the Editor, SMA News

Dear Editor,

I write in response to the article "Traditional Chinese Medicine - Friend or Foe?" by Dr Jeremy Lim in the March 2009 issue of SMA News.

While I understand that Dr Lim was writing in his personal capacity, and that his views do not represent those of the editorial board or SMA, I am nevertheless disappointed by his uncritical support for Traditional Chinese Medicine (TCM).

Dr Lim began his defence of TCM with the 'science was wrong before' argument. While he is correct in pointing out that Jenner and Semmelweis' views were rejected by their colleagues in their days, they were eventually vindicated via the scientific method - their findings were accepted to be true because they explained observed phenomena, and not because the medical community decided to adopt a different standard of assessing a scientific claim. Dr Lim could well have included Dr Barry Marshall as a recent example of a 'misunderstood innovator', but we should remember that in trying to gain acceptance for his theory he did not appeal for a different 'metric' to be applied to it, but sought to provide evidence by drinking H. pylori. Why should TCM be held to a different standard?

Dr Lim then went on to state that "Western medicine has no monopoly on knowledge and we must actively and aggressively seek ways to compare Western methods and TCM, finding metrics that can be applied equally to both." I would like to contend that this is a misrepresentation of Western medicine today. Western medicine"does not claim to have a monopoly on knowledge; what it does claim to have is a valid tool for assessing claims in the form of the scientific method. The scientific method make us test each claim by demanding observable evidence, and to abandon a claim or a theory if it did not fit observed phenomena - it contains within itself the mechanism to correct previous assumptions, and is in fact the method that vindicated Jenner, Semmelweis, and Marshall. In contrast, TCM is based on a pre-scientific theory of unobservable qi and meridiens. Neither of these entities have been demonstrated objectively, while at the same time efficacy from modalities of treatment used in TCM have been shown to be due to processes that can adequately be explained by modern science (pharmacological properties of active compounds in herbs, endorphins-production in acupuncture), yet both continue to be taught and used as if they were true - it is not Western medicine that is claiming monopoly in knowledge here. The "metric" that should and must be applied equally to TCM and Western medicine, and for that matter all forms of alternative medicine, is the scientific method - it has been an objective and reliable method for evaluating claims, and proponents of different "metrics" have yet to come up with anything as effective as it.

Dr Lim then quotes Dr Lee Tat-Leang on the difficulty in performing randomised controlled trials for TCM treatment modalities because they involve "individualized and prolonged treatment", and mentioned in particular the difficulty of finding an appropriate placebo for acupuncture. This argument is a poor defence for the lack of quality evidence for TCM since a randomised controlled trial is not the only acceptable form of evidence, nor does the design of a randomised controlled trial necessarily forbid "individualized and prolonged treatment". With regards to placebo for acupuncture, I would like to point out that that sham acupuncture in the form of blunt or retractable needles which do not penetrate the skin or needling at points which are not identified to be acupoints have been widely used and accepted as forms of placebo in acupuncture studies. A recent meta-analysis of 13 studies on analgesic effect of acupuncture and placebo acupuncture [1] showed no significant difference between the two, which supports the view that the theory of qi and meridiens upon which acupuncture is based is not an adequate explanation of observed phenomena.

While I agree with Dr Lim's next point that it is possible to study the use of TCM in clinical trials that look at objective parameters, I believe that the important distinction between the treatment modalities used traditionally in TCM and the theories behind it must be made. We must not commit the logical error of accepting the that the theories behind TCM are true simply because a certain modality (be it herbal remedy, acupuncture, or traditional massage) has shown efficacy, but continue to test each claim. More importantly, we must not be lulled into thinking that "patient satisfaction" is more important than scientific rigor, and that the "philosophy" behind the treatment is not important as long as our patients are satisfied. Such an attitude promotes complacency, and will allow other forms of unproven therapy or pseudoscientific "alternative" medicine to claim legitimacy.

Dr Lim ends his article with a commentary on how "Singapore's Unique Position" means we are well-placed to "critically appraise the different elements of TCM viz-a-viz Western medicine" because of our "greater understanding and respect" for TCM. I would argue that any presumption of "understanding" and any unwarranted "respect" for TCM may in fact be detrimental to scientific study as it would prejudice the investigators' minds. As for Dr Lim's question of whether we will "seize the opportunity" in "blending" TCM and Western medicine, I would like to point out that Germany and the USA have already been studying TCM for many years, with the US National Institute of Health having set up a National Center for Complementary and Alternative Medicine (NCCAM) to conduct research on TCM and other forms of alternative medicine. The German social insurance had a few years ago withdrawn reimbursement for acupuncture for treatment of certain conditions based on studies that showed no difference between acupuncture and standard treatment for these conditions (while inexplicably continuing to pay for those conditions where no difference was found between treatment with acupuncture and sham acupuncture), while NCCAM had spent more than US$800 million on research since 1991 but have not managed to demonstrate the efficacy of any alternative medicine - the "opportunity" had already been seized by other people, and I am not sure that was a loss to us.

Sincerely,
angry doc

1. Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ 2009 Jan 27;338:a3115.