Evidence‐based medicine and acupuncture: old bias for new perspectives in clinical context

From the moment that evidence-based medicine (EBM) was accepted by the predominant medical-scientific community, it has increasingly represented a refuge for medicine, which has voluntarily chosen to regard the validity of a theory and the truth in the same way. The introduction of placebo in a randomized controlled trial (RCT) serves as such [1]; in order to analyse the reality by dividing it into two poles, the true and the false and, by tertium non datur principle, effectively excluding any other possibility. All of this was legitimized by means of a methodic rigour, which not only excluded but also deprived value, resulting in everything that was either impossible to measure or standardize as unjustifiable [2]. If this measure of purification has permitted important and useful discoveries, it has, on the other hand, also deprived medical practice of a vision which does not fit into a characteristically pharmaceutical-centred one; for the present circumstances, the certainties on which that paradigm is based are weakening and creak like the floor upon which Ptolemy founded his theory. The crux of the matter, according to our point of view, lies in the presumed authoritarianism of a principle, whereas a shift in the parameter with which one makes a judgment is necessary, from truth to acceptance; paying attention to the historical aspect of scientific knowledge, highlighting extra-scientific conditioning factors that science is subject to, the negation of a fixed method of knowledge and, most of all, the consideration of theories not in terms of truth but of acceptance, all of which would appear to be fundamental aspects that have been forgotten by medicine following the fusion with the EBM model. For example, it would be necessary to remember that in order to obtain a single data from a series of results, a statistical calculation has to be applied which gives a frequentist probability, ideally referring to an infinite number of cases but deducted from a limited number of experiences. This information that has been obtained from a statistical study could be liable to inconsistencies, with the effect of leading to observing actual clinical cases. This clearly indicates that statistical and clinical significance do not coincide [3]. All of this has led to a sectarian conceptual narrowing, which is evident in the question regarding the definition of the placebo effect [4]. The condition of being able to know an object is determined by the ability to give that object a name, creating a possibility of studying a placebo phenomenon as an entity, ontologically speaking, or on the basis of the relationship between the knower and the object being examined, that is epistemological. This is not a detailed analysis that remains at a theoretical level only, but has, on the contrary, important practical repercussions. A number of questions arise, for example; how does one conceptually define the placebo? Is the placebo effect only that which fits into the therapeutic doctor–patient ritual or can the field of investigation be extended? If the cost of the medicine influences has an important effect on a therapy [5], do we still believe that there is a real distinction between specific and unspecific effects? More importantly, however, does the creation of this artificial separation make sense? Such doubts become even greater if the so-called ‘the efficacy paradox’ [6] is analysed, a phenomenon that comes about when two therapies are compared, of which the total efficacy of one of them presents a lower specific effect in contrast to a higher specific effect of the other which, however, has a lesser total efficacy. If all these epistemological issues represent a problem for biomedicine, the reasoning become more problematical for what concern traditional, complementary and alternative medicine (TCAM). TCAM presents in fact, intrinsic aspects that can hardly be understood or validated by the positivist epistemological paradigm through which modern biomedicine legitimates itself. The issue of placebo finds its raison d’etre on the basis, precisely, of this critical point and it is therefore necessary to ask if it is possible to speak of an ontology or an epistemology of placebo; if it is possible to study the placebo phenomenon as an entity or whether it would be more correct, rather, to speak of the relationship between the knower and the object under study. The imperialist mentality typical of the West appears to be an inheritance of a not-too-old past. It is a dangerous and harmful habit reflected in the way, through which biomedicine judges and utilize TCAM; in order to justify our point of view, we will take a deeper look into acupuncture. The predatory attitude is indeed, strongly present in the case of acupuncture for two main reasons: the lack of respect for context in which acupuncture originated (where it was not a separate treatment but a therapy in a complex health care system) and the adaptation imposed by biomedicine that acupuncture become plausible through its rules (those of biomedicine). For these reasons, there has not been progress, in the epistemological sense, of traditional Chinese medicine, but a ‘betrayal’ of this complex system of care that often results in a therapy being eradicated from its context [7,8]. This is done with great frequency in acupuncture because, on the basis of a diagnosis made according to the manual of biomedicine, the needles are inserted in a way that is unrelated to concepts of the five movements (elements), for example. Changing the context, however, radically changes the effect and the rationale that underlies it. It is also necessary to point that the traditional Chinese medicine is not the only medicine that uses acupuncture as a therapy; there are other methods such as Japanese and Korean (medicine) [9]. bs_bs_banner