Chinese medical practice in Taiwan, STS perspective

Systems Changes
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Taiwan is a good place to be studying hybrids of western biomedicine and Traditional Chinese Medicine, since there’s established practices that have become accepted over decades. (My personal experience of having been in Taipei is a strong predisposition towards an American style, with Chinese traditions).

Science and Technology Studies (STS) is a well-developed discipline in many universities. I hadn’t considered western medicine as a colonial discipline, yet am an exception in having been advised by both western-trained doctors and a TCM doctor for decades.

A case study is reviewed by Wen-Yuan LIN at National Tsing Hua University (Taiwan) and John Law at the Open University (UK).

Scientific evidence-based biomedicine is often distinguished from traditional experience-based CM [Chinese Medicine], but this is a recent distinction and is not what is happening here.5 People come for CM, but Dr Lee, with her double training, also offers biomedical examinations.6 Traditional herbal and SCM are prescribed. CM is being mixed with biomedicine professionally and pharmaceutically. CM practice is being hybridized. How might we think about this?

5 In fact, until modern state intervention in Taiwan and China, Chinese medicine (CM) was not a unified system but more like an assemblage of various schools of practices loosely connected with classics, techniques and medications shared in varying degrees (Hsu, 1999; Scheid, 2002, 2007; 皮國立, 2012; 林昭庚 et al., 2011).
6 However, unlike their colleagues in mainland China, Taiwanese CM doctors cannot prescribe biomedication and biomedical treatment.

One obvious response is that this is an expression of imperialism. STS has often described the hybridity and heterogeneity of imperialist science, technology and medicine. [p. 805]

Taking blood pressure, and then applying the technique of feeling for four pulses is an example of hybridity.

A nurse comes with a haemadynamometer, while, Dr Lee feels his pulsation in both wrists again. Then the nurse speaks: ‘It’s 102 over 78’. Dr Lee repeats: ‘102 over 78’, and keys the data into her computer. Then she checks the records, looks up at Mr Wang and asks: ‘How about the problem with your leg? Have you brought the examination results?’ Mr Wang gives her his blood test result and a leg scan report.

This is hybridity again. Dr Lee does the ‘four diagnoses’ (sì zhěn, 四診). She smells and listens, looks, asks, and feels Mr Wang’s pulse. This is CM at work. But she also takes his blood pressure and looks at the scan and blood test results. These belong to biomedicine. The different logics and cultural contexts of pulse-taking in biomedicine and CM have been widely explored (Kuriyama, 2002), but how does this work here?

The haemadynamometer and blood tests are tools for specific ways of knowing the body. Their results may lead directly to a diagnosis because they indicate what is wrong with – and usually within – the body: they are used to tease out the underlying causes of ill health. But the four diagnoses work differently. First, they do not look for direct underlying causes. No individual sign leads to a specific diagnosis. Instead, CM explores the person in a specific and located composition of embodied, emotional and social correlations (Zhang, 2007). Particular signs and symptoms are associated with diet, sleep, excretion, lifestyle, the emotions and the practitioner’s own training and contexts. So the four diagnoses do not see symptoms or bodies in causal contexts, but in situations that are themselves complex and correlative (Farquhar, 1994). So Dr Lee looks for what might be causing bodily disturbance, but she is not looking for an indi- vidual cause but trying to locate this in a specific context of correlative composition. This extensive situated correlativity is the second feature of CM. It is hybrid but it is also correlative. [p. 808]

But what should we make of the fact that Dr Lee checks both pulsation and blood pressure? One answer is that there are varying degrees of hybridization between CM and biomedicine. At one end of the spectrum, some CM doctors insist on traditional forms of practice. They prescribe herbal medication, perform the four diagnoses, avoid using biomedical instruments and even write notes in classical language using classical calligraphy. At the same time, others modernize CM by working analytically, using experimental methods and the technologies of modern science and engineering (Lei, 1999; Lei et al., 2012; Ward, 2012; 黃進明, 2007). As we can see, Dr Lee works somewhere between these two extremes. She keeps her medical records on a computer, prescribes SCM, uses biomedical devices and reads biomedical reports, but she still performs the four diagnoses. She also talks of ‘circulation of the blood and qi’ and uses situated correlative reasoning to specify problems. [p. 808-809[

How should we understand this? Our suggestion is that we should neither worry about the presence of biomedicine, nor reify biomedicine and CM as two separate unities, since in practice both are more or less messy (Farquhar, 1994; Mol, 2002, 2008; Scheid, 2002). Instead, and adopting what one might think of as a ‘situated reification’, our tactic is to ask what elements of ‘biomedicine’ and ‘CM’ are actually doing in specific situations. It is almost impossible to avoid all reifications while moving between conceptual systems, because completely dissolving into complexifications loses something important about fairly systematic differences (as between ‘CM’ and ‘biomedicine’). Authors who write about ‘China’ from a ‘Western’ perspective all run into a version of this difficulty (Hall and Ames, 1995). Here the distinction between (‘Chinese’) ‘correlative’ and (‘Western’) ‘analytical’ practices is a ‘situated reification’. Our focus is on how hybridity might work in practice – and then on how this might help us to think about more appropriate modes of betrayal. [p. 809]

Reference

Lin, Wen-yuan, and John Law. 2014. “A Correlative STS: Lessons from a Chinese Medical Practice.” Social Studies of Science 44 (6): 801–24. https://doi.org/10.1177/0306312714531325. [alternate search on Google Scholar]

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In a subsequent article by Lin, the nuances of a practitioner with medical knowledge (from a western static predisposition) and contextual knowing (from the more fluid Chinese philosophy) is illuminated through an appreciate of shi, leading to an emphasis on propensity.

It is the compositions of the herbs rather than each individual ingredient that is important. Drawing on principles from formulary classics, Dr. Hsu explains:

Generally speaking, in FGD ginseng is for supplementing qi and bai zhu, fu ling are for fortifying spleen…. But it is not like biomedical drug where ingredient A is for problem A…. By “traditional” we do not simply mean that it is an herbal decoction, but also that it uses the [interactions between] sovereign, minister, assistant and courier in composing a prescription for correcting the biased inclination of the disease propensity (bìng shì piān xìng, 病勢偏性)[of the body].

What is disease propensity (病勢)? What do the herbs do in matching a decoction for correcting the propensity? How does the reasoning of sovereign, minister, assistant, and courier intervene in this? And how does KSY work on cancer patients’ disease propensity?

To answer these questions, we have to step outside modern science, immerse ourselves in the world of CM, and understand its cosmology. In these, the world is made of the “ten thousand things” (wàn wù, 萬物) and the qi of yin-yang circulates through the ten thousand things in the dynamics of five phases. The human body is part—but only a part—of this process. Propensity, shi (勢), is a style of reasoning for conceptualizing the immanent movement and circulation of qi. Here we need a health warning. To talk of “reasoning” is potentially misleading. The concept shi (勢) fits the English language poorly because it “inserts itself into the distinction between what Westerners call ‘practice’ and ‘theory’…thus collapsing the distinction” (Jullien 1995, 38).

One consequence of this is that how shi (勢) is translated into English depends on context (Sun Tzu 1993, 73).5 This is partly because, as Jullien (1995) puts it in his extensive examination of Chinese classic thought, shi “seems torn between points of view that are apparently too divergent, is nevertheless a possible word with a discoverable coherence…with an illuminating logic” (1995, 12-13). Thus, he mobilizes terms like “deployment,” “setup,” “propensity,” and “tendency” and their interactions to establish a framework that convey themes that include: [p. 411]

5 This processural and configurative concept is distinct from familiar English though and it is sometimes translated into “strategic power” (Sun Tzu 1994), “strategic advantage” (Sun Tzu 1993), “condition” (Wang 1997), “event” (Laozi, Ames, and Hall 2003), or “environment” (Lao Tzu 1989).

An inherent potentiality at work in configuration (whether in the deployment of armies on the battlefield, the configuration of an ideogram set down in calligraphy and a painted landscape, or established by literary signs); a functional bipolarity (whether between a sovereign and his subjects in a political situation, between high and low in aesthetic representations, or between the cosmic principles “Heaven” and “earth”); and a tendency generated sponte sua simply interaction, which proceeds to develop through alternation (whether, again, it involves the course of a war or the unfolding of a work, a historical situation or the process of reality as a whole). (1995, 14-15; italics in original) [pp. 411-412]

Here we focus on how it works in practice—and more generally how CM understands its practices. So how does the concept of propensity, shi (勢), work? The answer is that it offers a particular way of understanding the relations between “theory” and “practice,” knowledge and the world, situation and movement, and practitioner and practice. Consider the yin-yang figure in tai chi (tài jí tú, 太極圖):

In Chinese classical thought, dispositions are fluid and are expressed in relational configurations. Yin and yang are not a dualism but correlative opposites in a state of constantly changing movement. When they are in balance, each is implied, rooted, and contained in the other. Each has the propensity to contrast with, balance, control, and convert itself into the other (Wiseman and Ellis 1995). This correlative dynamic6 runs through the ten thousand things: celestial bodies, seasons, directions, locations, food, social relations, gender, personalities, painting, calligraphy, the mar- tial arts, military action, power, and medicine (徐復觀 1999).

6 See Needham (2005, 253-345), for an extensive discussion of correlative reasoning and its significance.

Propensity, shi (勢), is thus about movement and disposition toward movement. Unsurprisingly, “reasoning as propensity” weaves its way through Chinese traditional knowing practices. For example, in the Dao de Jing (道德經), the ten thousand things are formed in a process: “Tao gives them life. Virtue nurses them. Matter shapes them. Propensity perfects them” (Lao Tzu 1989, chap. 51, p. 105) [p. 412]

Reference

Lin, Wen-Yuan. 2017. “Shi (勢), STS, and Theory: Or What Can We Learn from Chinese Medicine?” Science, Technology, & Human Values 42 (3): 405–28. https://doi.org/10.1177/0162243916671202. [alternate search on Google Scholar]

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The western conception of disease coming from a pathogen contrasts to the Traditional Chinese Medicine view of a context-specific embodiment. Continuing with Lin (2017) …

Propensity and Intervention

CM follows this pattern. One of the earliest collections of CM classics, The Yellow Emperor’s Inner Canon (黃帝內經, hereafter Inner Canon), notes that: [p. 412]

When a physician of high level diagnoses and palpates, he always notices the order of priority of yin and yang, infers the Sixty Propensities of Ordinary and Extraordinary, synthesizes the small and fragmentary cases obtained from diagnosis, and weights the changes in yin and yang to know clearly the location of the disease in the five viscera, and then infers the medical principle and the outline of depletion and repletion to judge according to the five standards. (Wang 1997, p. 483; slightly adapted and shi is translated as “propensity” rather than “condition”)

In this way of thinking, a diseased body is one that deviates from its ordinary and balanced course, and medical intervention is a matter of understanding the propensity, shi (勢), in question and manipulating the configuration in order to rebalance it. This is further illustrated in the pioneer CM clinical classic, Treatise on Cold Damage Diseases (傷寒論; 東漢‧張機 1978), which differentiates disease propensity and formula of decoctions (tāng zhèng, 湯證) in terms of the six warps. 7 [p. 413]

7 The six warps are six categories of pattern differentiation: mature yang (tài yang, 太陽), yang brightness (yáng míng, 陽明), immature yang (shào yang, 少陽), mature yin (tài yīn, 太陰), immature yin (shào yīn, 少陰), and attenuated yin (jué yīn, 厥陰).

This means that CM does not prioritize pathogens in tackling disease condition. Rather, it is a context-specific embodiment between the person, her emotions, and the environment. It follows that diagnosis varies. Doctors from different schools (liú pài, 流派) might not agree on the cause of disease in a person and might devise different analyses8 to differentiate between patterns9 and devise a strategy (lùn zhì, 論治) to rebalance the imbalanced propensity (Farquhar 1994, 61-146; Scheid 2007).

8 Such as using the six warps (liù jīng, 六經), the visceral systems (zàng fǔ, 臟 腑), the eight rubrics (bā gāng, 八綱), or the four sectors (wèi qì yíng xiě, 衛氣 營血) analysis.
9 While the idea of “patterns” differentiation is a contemporary hegemony created in the political synthesis of CM and the term “disease” (bìng, 病; without the ontological implication) and “syndrome” (zhèng, 症) are also used alternatively (Scheid 2002), the propensity principle applies. See Scheid (2014), for genea- logies of CM’s notion of pattern.

For STS (Science and Technology Studies) researchers, Lin suggests shifts in 4 ways (that we’ll leave to the full article, for the diligent reader).

So what does this tell us about the STS terms of art mentioned above? Of relationality, heterogeneity, process, and situatedness? How do these work as equivocations? [p. 420]

If we put Western biomedicine and Traditional Chinese Medicine on the same level, what would be the result?

So shi (勢) is being lost in STS translation, while the asymmetry between Western theory and subaltern “case study” is being reproduced. But what would happen if shi (勢) were treated as a term of art in STS theory? A provisional answer is that STS might attend to balance and imbalance, to the normativities intrinsic to balances and imbalances, and intervene locally and tactically by following shi (勢) and doing not doing (wú wéi, 無為). This deserves further elaboration, and Dr. Hsu points to how this might be done. Doing not doing is not no action at all. It is the art of manipulating the situated shi (勢), with the normative inclination to follow the right way and right qi, which tend to keep things in balance. […]
“Balance” and “imbalance” are scarcely topics central to present-day STS. Normativities are important but are not usually integral to empirical description. And the idea that we might do by doing not doing is also mostly absent in a discipline which attends to the explicit and seeks to make strong arguments. Perhaps, then, shi (勢) might intervene in an STS intellectual imbalance by manipulating an intellectual disease of postcolonial asymmetry. This is the idea that theory is separable from “case,” and the (admittedly contested) assumption that theory is generally applicable and can travel anywhere (Law and Lin forthcoming)

Reference

Lin, Wen-Yuan. 2017. “Shi (勢), STS, and Theory: Or What Can We Learn from Chinese Medicine?” Science, Technology, & Human Values 42 (3): 405–28. https://doi.org/10.1177/0162243916671202. [alternate search on Google Scholar]