Over the last few decades there has been a steady infiltration of acupuncture into Western mainstream medicine. It is not unreasonable to conclude that acupuncture’s journey from an exotic Eastern practice to a fringe treatment to mainstream acceptance has been complete. Knowledgeable proponents of science based medicine (SBM) who remain skeptical of acupuncture now find themselves on the fringe. How did this happen?
Any complex cultural phenomenon is going to have multiple causes. Acupuncture is basically the poster child for all the inadequacies in academia and medicine in terms of how such issues are dealt with. Most medical professionals simply are uneducated about the details, they have out-sourced knowledge of acupuncture to the “experts” (proponents), there is a layer of reluctance to criticize born of cultural sensitivity, and there are still perverse incentives throughout both scientific and medical institutions.
But I will argue that core to acupuncture’s success is the rise of evidence-based medicine (EBM) starting in the late 1980s. Proponents of acupuncture have expertly exploited all of the weaknesses and shortcomings of EBM, which is why it is probably the best example of why we need SBM. As a treatment acupuncture is also optimally positioned to exploit EBM.
What Is Acupuncture?
We have explored acupuncture at length on SBM, but for a quick overview, acupuncture is the practice of sticking thin needles into specific points on the body in order to influence the flow of chi (a life force) to treat symptoms and diseases. Historically, acupuncture was more similar to blood letting than its fairly recent incarnation, and acupuncture points were essentially astrology. The whole using very thin needles and chi thing is a modern retconning of acupuncture created when various mutually incompatible traditions were united into “Traditional Chinese Medicine” (TCM).
A post-modern, if you will, further retconning of acupuncture by some contemporary proponents try to eliminate reference to chi or life force, and instead invoke a poorly defined and understood mysterious physiological mechanism from sticking needles into acupuncture points. But even in this formulation – acupuncture, by definition, requires sticking needles into acupuncture points.
EBM on Acupuncture
You can search for articles on SBM vs EBM here to get a detailed discussion of what we consider to be all the salient differences, and proponent of EBM will disagree on how best to implement EBM in practice (with some essentially morphing it into SBM and even claiming that is what it was all along). But at its core, EBM relies upon the highest quality clinical evidence to test the safety and efficacy of specific health interventions. While this sounds great, David Gorski has termed this “methodolatry” because it focusses too narrowly on this one method, while ignoring vast swathes of science.
A narrow focus on such clinical trials allows for a lot of abuses – including p-hacking, publication bias, poorly defining terms, inadequate blinding, and mixing variables. SBM takes a more thorough approach that tries more rigorously to control for all these things by looking at the overall patterns of evidence in the literature. SBM also explicitly considers scientific plausibility and prior probability, and prefers a more Bayesian approach to statistics.
In brief – acupuncture exploits all of these weakness of EBM. Acupuncture studies mix in variables like “electroacupuncture”, allow study designers to choose acupuncture points ad hoc without any internal consistency, rely heavily on poorly blinded or even unblinded comparisons, and claim that when “placebo” or “sham” acupuncture work as well as “verum” or true acupuncture, that just means that these other forms of acupuncture also work. P-hacking is rife within the acupuncture literature. Further, when looking at studies from China, publication bias is literally 100%.
Acupuncture also is almost designed to maximize placebo effects. It is an elaborate ritual, involves an invasive procedure, and involves a lot of hands-on attention and positive encouragement from a practitioner.
But – using EBM you can generate some statistical outcomes that proponents can point to in order to claim that acupuncture is “evidence-based”. This has become a powerful tool for promoting acupuncture to mainstream professionals. There is also just enough superficial plausibility, since something physical is actually happening (unlike, say, in homeopathy). Acupuncture researchers have also focused on the subjective symptoms that are most amenable to placebo effects to make their case.
The SBM Approach
When stepping back and taking a full SBM approach to acupuncture, a very different picture emerges than the narrow EBM approach. The plausibility of acupuncture is very low, because there is no known mechanism, and outside of short term pain and nausea reduction, for any medical application of acupuncture there is no plausible even theoretical mechanism.
Perhaps most devastating is that, even after extensive research, acupuncturists cannot demonstrate that acupuncture points exist. They cannot even agree on where they are and what they do. In short – scientifically speaking, acupuncture points don’t exist. If that’s the case, than acupuncture itself does not exist. From a basic science perspective, acupuncture fails utterly.
From a clinical research perspective, it also fails. Systematic reviews have failed to show a consistent replicable and specific effect from acupuncture. This is true despite decades of research and thousands of studies. If there were a real effect there, we should be clearly seeing it by now, but we are not.
What the clinical research does reflect is mostly small and poorly designed studies, with the better studies tending to be negative. There is lots of p-hacking and publication bias. There is also a great deal of heterogeneity – different acupuncture points and different outcomes. In other words – the acupuncture literature in total has all of the red flags and features of an intervention that does not work. If you compare this with a dubious history and lack of plausibility, the only SBM conclusion is that acupuncture does not work.
And yet it is increasingly promoted as an evidence-based treatment. This, however, reflects only the failure of EBM to properly address the question.
