A Chinese medicine oath serving as a foundation for acupuncture medical ethics

This is the second portion of the paper I read at the 2017 SPCW annual meeting. You can read the beginning here. I’ve not made many changes I would like to make quite yet, but wanted to get this second part up. I’ll make some changes to it in the coming weeks, and reflect the date of those changes here. Thanks for reading and I look forward to your feedback!

Let’s proceed to the oath, but first, why oaths? I assert that oath making in a professional context has utility in my analysis in part because it represents the collective promise made by individual practitioners as they enter a new professional context. As such, it can be seen as the backbone of acupuncture medical ethics as actually practiced. The nature of this promise, and the reality of its adoption in practice, is a useful way to understand the culture of the profession. The oath, which I share in full below, is adapted from a passage by 6th century Chinese medicine physician, Sun Simiao and is in active use at many institutions of EAM in the US.

For reference, I number each statement of the oath in parentheses.

“I promise to follow the way of the Great Physician (1). I will strive to live in harmony with nature, and teach my patients to do the same (2). I will stay calm and completely committed when treating disease (3). I will not give way to personal wishes and desires, but above all else hold and nurture a deep feeling of compassion (4). I will be devoted to the task of saving the sacred spark of life in every creature that still carries it (5). I will strive to maintain a clear mind and am willing to hold myself to the highest standards (6). It will be my duty to diagnose sufferings and treat disease (7). I will not be boastful about my skills nor driven by greed for material things (8). Above all, I will keep an open heart (9). As I move on the right path I will receive great happiness as a reward without asking for anything in return (10).”

The oath begins with, “I promise to follow the Way of the Great Physician (1).”

This opening statement, combined with aspects of statement 6 (“hold myself to the highest standards”) comprise Principle A of this paper, which I summarize as a promise to “know and utilize EAM traditions.” At first glance, this is simply an assertion of the importance of the medical tradition and the practitioners who have worked to advance it. EAM has a long history of mentor-student transmission and veneration of ancestors, so it makes sense that the oath would reference tradition.

However, with knowledge of the history, language and literature of Chinese medicine we can also see larger symbolic references at work. When the oath refers to the “Great Physician” it recalls information available in the historical literature about the ideal EAM practitioner. EAM texts such as the Huangdi neijing suwen and Shang han lun referred to this ideal practitioner as the 大藥 da yao, great physician, or 上工 shang gong, superior practitioner. Classical Chinese medical texts of many eras discuss the specific features of the Great Physician and the great benefits patients receive when being treated by her.

Exploring the intricacies of this ideal practitioner construct is beyond the scope of this paper. However, I argue that the idea of Shang gong is more fully described by the rest of the characteristics listed in the oath (Principles B-D). In other words, a Shang Gong, is the type of person practitioners study and imitate in order to “follow the Way of the Great Physician.” As such, we’ll learn more about what it means to embody this principle as we proceed.

The second oath item tells practitioners that they must “…strive to live in harmony with nature, and teach [their] patients to do the same.”

For the purposes of this paper, I name this principle B, and summarize it as “center nature personally and professionally,” which I sometimes shorten to “nature centeredness.” This is a rather vague principle as the oath text doesn’t contain explicit instruction concerning what it means to live in harmony with nature. A more detailed etymological analysis of the source text could reveal more of the intent of the author. Proceeding without that, I will merely assert that a concept of “harmony with nature” exists at every level of theory and practice of EAM. By way of example consider the well known pathophysiological concept of the five phase elements, or just “the five elements”.

These are a foundational theoretical construct in EAM and are modeled after basic substances on our planet – water, wood, fire, earth and metal/ore. Consideration of the essential nature of these substances and their interaction, with some help from additional theoretical constructs, allows practitioners to characterize disease in a simplified way that eases both diagnosis and treatment. Whether this is a valid form of medical reasoning or not is not the point, here, instead note that this foundational concept of the medicine – known by nearly every person who knows anything about EAM – is nature based.

EAM oath statements 3, 5, 6, 7 & 9 are most usefully seen grouped under a similar theme, which I summarize as “focus on personal development and cultivation.”

Like principle A, this concept is reflected in many of the classical texts and teachings of EAM. In every Han dynasty (206 BCE – 220 CE) medical text there are references to the critical importance of healthcare practitioners attending to their own cultivation. In a sense, practitioners attending to their own care & development forms the bedrock foundation of what a EAM practitioner is meant to be, traditionally, and so within the context of this oath. To be a 上工 shang gong, in other words, a practitioner must be attending to their own physical, emotional, social, mental and spiritual needs.

Personal development is not monolithic, of course, and the oath statements actually reference more than one type of self cultivation that is important to the practitioner. The list of desirable qualities mentioned in the oath include mental clarity, dutifulness, devotion and compassion. These qualities should be familiar to anybody who has studied virtue ethics, and indeed a deeper analysis of how various perspectives in virtue ethics relate to my discussion would be valuable.

I group oath items 8 and 10, and to a lesser extent 4, and summarize their combined principles as encouragement for practitioners to “focus on non-material rewards.”

These oath items are actually describing a subset of the character traits described in principle C. Principle C of the oath involves practitioners promising to attend to their inner cultivation – to develop those virtues useful for medical practice. Principle D indicates one of those virtues that is of particular interest, at least in the context of this statement.

As today, the ability to achieve fame and accumulate wealth was possible for medical practitioners in dynastic China. Based on Principle D, excessive focus on this accumulation is discouraged. What is the substance of the concern in this oath about focusing on material rewards? In statement 8, a practitioner promises to “not be boastful about their skills, nor be driven by greed for material things.” In this statement, the key word is “driven,” because it indicates that the practitioner’s primary motivation is the acquisition of material things in exchange for practice.

Here, then, there is no suggestion that practitioners must be destitute, only that they should primarily orient themselves around other rewarding aspects of practice.

To summarize, my analysis uncovers four principles in the standard EAM graduation oath. First, to learn and use the EAM traditions, second to center nature personally and professionally, third to focus on personal development of virtues and fourth to focus on non-material benefits of practice. I assert that these four principles have several important uses for practitioners and teachers in EAM, and can serve as a starting point for the intentional creation of EAM professional culture in the US. I now proceed to consider just one of these principles in more detail, describing the potential practical effects of incorporating it.

Principle B, which I’ve summarized as “center nature personally and professionally” is of particular interest as we face planet-wide ecological crisis. I’ll follow up focusing on this principle in some detail in the next installment of this short series.

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