All posts by Mikael Ikivesi

Mikael Ikivesi is a Finnish acupuncturist, who has been studying and practicing Chinese medicine since 2001. He is chairman of The Finnish Traditional Chinese Medicine Society of Acupuncture and Herbs (Finnacu). His personal interests are medical traditons of China and their connections to self cultivation practices.
Chinese & East Asian Medicines, Global Asian Medicines

Can use of acupuncture delay proper medical treatment?

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Introduction

Even though there is room for more thorough adverse effect reporting in acupuncture trials and a need for more studies about acupuncture safety (Ng et al. 2016; Turner at al. 2011), there already exists evidence concerning the safety of acupuncture. Based on the studies (Witt et al. 2009; Kim et al. 2016; McCulloch et al. 2015; Park et al. 2014; Houzé et al. 2017), we can conclude that generally acupuncture can be seen as a relatively safe practice. The adverse effects from acupuncture are extremely rare compared to reported adverse effects from conventional medicine. The FDA Adverse Event Reporting System (FAERS) Public Dashboard reveals 906,773 serious side effect reports and 164,154 deaths from side effects or malpractice in 2017 alone. This is an unfair comparison as the patient base and seriousness of the conditions treated are often very different, but it gives us a perspective to the safety of acupuncture in comparison with many other medical treatments. And even the most serious side effects like pneumothorax from acupuncture seem to be preventable with sufficient training in acupuncture education (Kim et al. 2016).

In the acupuncture studies about patient safety, the subject has been approached from the point of safety of the treatment itself. There seems to be a lack of studies about the possibility of delayed medical treatment in cancer or other severe medical conditions due to the use of acupuncture. This essay approaches the subject with reflection on a patient case.

Case background

The author first met the patient in 2011. The patient had suffered from recurring, almost constant uveitis for 15 years. Known causes of uveitis had been previously excluded by medical doctors. The only treatment offered to the patient was ophthalmic steroids. Prolonged use of the steroids had increased her intraocular pressure causing glaucoma that threatened her diminishing vision. The ophthalmologist wanted to start a more robust and constant medication for glaucoma with a drug having the side effect of flaring of uveitis. The patient wanted to try acupuncture as an alternative.

After five sessions of acupuncture, the symptoms of uveitis had clearly decreased and she had reduced the use of corticosteroids. She had permission from the ophthalmologist to dose corticosteroids based on need. During the following months, she used them only twice when she felt any peculiar feelings in her eyes. Five months later she visited her ophthalmologist who could not see any signs of uveitis. Due to increased intraocular pressure, they had agreed for regular follow-ups. Beside one occasion in 2012, she has been without corticosteroids and free from uveitis.

In addition to uveitis, she had a medical history of back and joint pains, and Ménière’s disease.

During her initial visits to author’s clinic, she expressed her growing frustration with medicine and how she felt like a test subject. The doctors could not give a reason for her symptoms, and to her it seemed illogical to use medication causing uveitis to treat problems caused by the medication for uveitis. She also felt that some doctors she had met had been unprofessional in their behaviour. Side effects and dissatisfaction to conventional health care are among common reasons for trying acupuncture (Jakes et al., 2014).

Radical change in patient’s health

In 2015, the patient wanted to try acupuncture for fatigue. She had already visited a medical doctor through occupational health care who didn’t find anything alarming. The author performed acupuncture based partly on her previous background information and her current symptoms. Afterwards, she reported a slight initial improvement, but the exhaustion soon returned and was non-responsive to further attempts with acupuncture.

After a third acupuncture treatment she caught a flu and visited another doctor who took a chest X-ray that revealed a cancerous growth in her lungs. The patient was treated with surgical removal of the tumour. Because of inappropriate joking by the operating doctor just before the surgery, she felt mistreated again even though the surgery was successful. Soon after the surgery she contracted pneumonia. During follow-ups later on, her papers were not read properly leading to surgical marks visible in the X-ray to be mistaken as a sign of pulmonary embolism. Two months of unnecessary subcutaneous injections added to her mistrust of the whole medical profession even though the surgery itself had been successful.

During these events the patient contacted the author and told him about the correct diagnosis. She didn’t blame the author for misdiagnosis. But for the author this caused concerns and a need for reflection. How could something this serious be missed even when the cancer was advanced enough to cause serious fatigue? Could this be prevented from happening again?

Meeting in 2017

In 2017, the patient reserved time from the author because of vertigo caused by Ménière’s disease. The prescribed medication was no longer effective. During the meeting she gave a detailed account of her experience with surgery and how she felt afterwards. She was angry and frustrated and said she had little faith left for the health care system even though she had been saved by the medical procedure. During the session she gave permission for using her case as a case study. After giving the permission, she was told that the treatments would be free of charge.

Meeting her after the incident produced conflicting thoughts. Because of her past, the current condition felt more alarming. Why did her medication suddenly stop working? Was the dizziness caused by Ménière’s disease, a simple benign positional vertigo or was it something more severe? What if this was somehow connected to her previous condition? There was also curiosity and a need to ask questions about her previous health concerns that might shed some light to the author’s wrong diagnosis.

She had already seen her physician to screen out anything serious but still the situation stirred some insecurity in the author. During the discussion and diagnosis she revealed that she had recently lost her job and was now unemployed. So she was particularly happy to receive free treatments. Lack of money combined with free treatments might also increase the possibility of an already vulnerable patient to feel more dependent on the acupuncturist or it could produce a feeling of groundless gratitude. Having less money might also mean that she might be less willing to see a doctor in case the acupuncture treatment did not work, especially with her experiences with the public health care.

While describing her experiences and expressing her mistrust with the medical profession, she didn’t seem to consider the author to be part of the medical profession. In Finland, the author is a registered health care professional due to being a licensed masseur, but an acupuncturist is not an accepted health care professional nor is there any legal regulation about the profession. The professional associations are working to self-regulate the field, set educational criteria, enforce the following of ethical guidelines, and ensure that the professionals have proper insurances.

For the author, it was important to meet the patient face to face after making a wrong diagnosis. There were no signs of blaming or mistrust from the patient. Her patient records had been reviewed in 2015 and again before the appointment. There was no evidence of neglecting of symptoms, and she had already visited a medical doctor beforehand. It was crucial for the improvement of practice for the author to become more aware of possible consequences. It made the author question his own responsibilities and also the boundaries of his practice.

Analysing the case

During 2015, the author had failed to recognize lung cancer. The examination and questions asked during the visit could have been more thorough. Owing to the fact that the patient was previously known, there was a possibility of using information gathered during earlier visits. This combined with the shorter time reserved for returning patients might have made it harder to be cautious enough. The TCM diagnosis based on the discussion, pulse, and tongue during the visit revealed what is known in Chinese medicine as a deficiency of blood and a weakness of lung qi. Relying on the patient history while formulating a picture of the current situation might have affected the understanding of the real reason for exhaustion and how serious her case was. The medical expertise of the author did not enable him to recognise the underlying reason. A similar mistake was probably made by the medical doctor in occupational health care who failed to see cause for further tests. Given the patient’s earlier bad experiences with health care, she probably might not easily go back for a second opinion. In this case, it was pure luck that the patient caught the flu and was sent to x-ray.

The seriousness of the situation also raises other concerns. What if the patient had gotten better results from the acupuncture treatment? In that case, could the better results have delayed a proper diagnosis and medical treatment? And what role does the therapeutic relationship play in a possible delay of proper treatment?

There exists some evidence that acupuncture is effective in treating cancer-related fatigue (Duong et al. 2017; Zhang et al. 2018; Zick et al. 2016). These studies focus on fatigue in connection with conventional cancer treatments, but acupuncture might also diminish the fatigue caused by cancer itself. Definite scientific evidence for the effectiveness of acupuncture for cancer pain is still lacking (Wu et al. 2015), but there is reason to believe that acupuncture might provide some relief from cancer pain (Hu et al. 2016; Chiu et al. 2017). So there is a possibility that acupuncture might prolong the time before the patient goes to see a doctor. An acupuncturist might see diminished fatigue and/or pain as evidence of successful treatment, which might in reality delay proper medical treatment. However, in case of pain, the same could easily happen with self-administered and commonly available pain killers. The fatigue might also diminish with energy drinks (Warnock et al. 2017), but the effects wouldn’t probably last for long. However, it could also be possible that by visiting an acupuncturist frequently, the acupuncturist could notice if there was no response to treatment or that the results were not as long-lasting as they should be. At least the acupuncturist would notice if the condition of the patient seemed to deteriorate despite the treatments. This could easily alarm a professional acupuncturist so, in this way, the acupuncturist would provide an extra pair of eyes watching for the patient’s health. In Finland, the acupuncture associations require the signing of ethical conduct which states that all acupuncturists refer cases to medical doctors when medical treatment is needed.

A study by Shorofi and Arbon (2017) offered some reasons why patients are opting to use CAM therapies instead of medical therapies. In the study, in all the people opting for CAM therapies, the most relevant reasons for this case study were that the problem was not seen serious enough to see a doctor (21.4%), a belief that these alternative treatments have fewer side effects than conventional ones (16.9%), and dissatisfaction with conventional treatments (6.8%). Combining these percentages with those of people who felt that CAM therapies were more fitting to their personal lifestyle or philosophy (37.7%), there is some evidence of a group of people who might not prefer to see a medical doctor in the first place. The study was done among hospitalised patients in Australia, but the author is in agreement over these patient groups and confirms similar numbers based on his own patient records and experience.

In serious diseases, like cancer in this case, medical diagnosis and intervention as early as possible is paramount. The symptoms, however, can begin with only minor health complaints. The 21.4% of population who use complementary modalities consider their problems not serious enough (Shorofi and Arbon 2017), but they might still find their way to the acupuncturist who, with adequate training, could be able to recognise the severity of the symptoms and could advise the patient to see a doctor.

The example patient in this essay had a medical diagnosis from her ophthalmologist for her previous condition. But in Finnish acupuncture clinics, it is very common to meet patients with medically unexplained physical symptoms (MUPS). These patients do not have a diagnosis and often feel that in conventional medical care they are misunderstood and their symptoms are not always taken seriously (Lipsitt et al. 2015). This same patient group generally obtains poor clinical outcomes from medical practice (Lipsitt et al. 2015), which might lead them to further avoid medical doctors. Some of these patients might feel more understood by CAM practitioners in general. Depending on the type of therapy, this could partly be due to the duration of initial interview and time used during the treatment, or more cosy clinical settings. It might be the CAM practitioner who first notices that their symptoms start to change or become worse, signalling that there might be a need to see a doctor. However, if the CAM therapist fails to see the alarming signs, the patient might get non-optimal treatment and believe that he gets all the treatment he needs. This could be preventable with proper education and further cooperation with medical doctors.

An even more alarming group than the MUPS patients who often burden health care with their constant visits (Lipsitt et al. 2015), are those who feel very dissatisfied with their medical care and are avoiding seeing doctors. This group is easily left without treatment by their own choice. Some of these patients might still be willing to see an acupuncturist. In that case, more serious and easily recognised problems might become apparent and they could be referred to health care, if they can be persuaded to make an appointment. Within these patient groups, there are people who feel vulnerable and, sometimes, they do not know where they should go and which symptoms they should tell their doctors. In their case, even one bad experience with a medical doctor can lead to further aversion of medical procedures and tests. For them an acupuncturist might be seen as a neutral bridge for communication to conventional health care.

CAM modalities are also often selected because of recommendations or wanting self-control over an illness (Shorofi and Arbon 2017). Many patients from the group who feel CAM therapies are more fitting to their personal way of life may not easily visit a doctor for any minor complaints. Based on the author’s experience, the people from these groups are generally willing to see a doctor when faced with any serious conditions or when told so by an acupuncturist. The problem for these patients is to recognise what is relevant and what is serious enough. Those seeing an acupuncturist with at least a basic education of medicine, could then be told by the acupuncturist to see a doctor if needed.

Conclusions

The failure to recognise lung cancer by the author and by a medical doctor in occupational health care was a human error. The proper acupuncture studies in Finland include a minimum of 14 to 30 ECTS of medicine, depending on the year of graduation, and lung cancer is one of the most difficult forms of cancer to diagnose even for general practitioners (Rankin et al. 2017). Mistakes can happen for any medical professional and CAM practitioner alike, but delays in treatment can lead to disease progression and missed opportunities for cure in a significant subset of patients (Rankin et al. 2017). In conventional care, it is customary to refer the patient to a specialist for diagnosis in case the general practitioner suspects cancer or another more serious disease. A similar attitude is crucial for patient safety among all CAM modalities. Wide cooperation with medical doctors would ensure patient safety and could also encourage some vulnerable patient groups to visit a doctor in time. It might also provide a bridge for communication to patients with MUPS or other patient groups who may feel more understood by CAM practitioners.

Based on these reflections, the author claims that there exists a possibility for certain groups of people to be left without early recognition of serious diseases in conventional health care and in clinics offering CAM modalities. In developed Western countries, most patients already go to a medical doctor in case they suspect anything serious. Those coming to see an acupuncturist or another CAM practitioner have often already visited a medical doctor (Eisenberg et al., 2001). Those who have considered their problems too minor for needing a doctor may still try acupuncture. In case the acupuncturists suspect any more serious health concerns, the professional acupuncturists always ask the patient to visit a doctor. In Chinese medicine education, it is necessary to teach acupuncturists to become aware of their own limitations. In acupuncture education, the students need to be taught to communicate with the patients honestly, if they cannot understand the symptoms or they have any suspicions.

The ability of an acupuncturist to recognise important clues about serious health issues depends on education and clinical experience. Even though Chinese medicine courses are not meant to produce medical doctors or to teach how to make a conventional medical diagnosis, they aim at providing enough understanding when it is necessary to refer the patient to medical care. As the popularity and acceptance of acupuncture is growing fast and more and more research about its effectiveness is emerging, the acupuncturists will receive more and more patients seeking alternatives. With growing public awareness of acupuncture, there will be more and more patients coming with grave illnesses that require conventional medical treatments. The need for basic medical education and continuous education for acupuncturists cannot therefore be stressed enough.

It is also crucial for acupuncturists, and other CAM practitioners, to network themselves with medical doctors whom they can refer the patients to or ask for an opinion. Awareness of these critical situations can also be improved with open discussion and sharing experiences with other acupuncturists or practitioners of other CAM modalities.

Some patients have withheld information from their doctors about their nutraceuticals recommended by their nutritional therapists or herbs recommended by CAM practitioners. In the study by Eisenberg et al. (2001), three fifths of CAM therapy used was not disclosed to doctors. The common reason is that the doctor didn’t ask and some patients were also afraid that the doctors would not agree or understand (Eisenberg et al., 2001). This can be very dangerous considering the potential interactions (Salminen, 2018) with drugs used in cancer treatment, for example. The possibility that the patient uses some CAM modality is ever increasing. According to Eardley et al. (2012) “the prevalence of CAM use varied widely within and across the EU countries” and could be even as high as 86% of the population in some countries. The most commonly used modality is herbal medicines. If the patients sense a strong dichotomy between CAM practitioners and medical professionals, it can cause the patients to withhold vital information. It is important that acupuncturists also recognize these dangers and are able to inform their patients and form patient relationships based on trust. They need to tell their patients to inform their doctors or practitioners of other CAM modalities about any treatments they give, especially if they prescribe any medicinal herbs or products.

The acupuncturists and Chinese medicine practitioners might also hear about the use of falsified medicines that can endanger the patients (Hamilton et al. 2016) or other unregulated and possibly harmful products. The acupuncturists can report these potentially harmful products to local authorities and inform their patients about possible dangers in their use. The author believes that information about the use of unregulated or falsified medicines might be left out during visit to a doctor just as easily as the patients withheld information, such as using CAM modalities, and an acupuncturist can instruct their patients to disclose this information.

With patients having any previous dissatisfaction with medical care, extra caution should be taken. In case of any suspicious symptoms, the patients should be instructed to see a doctor, if they have not already done so, to avoid a late diagnosis of serious medical conditions. Making patients agree to see a doctor probably requires building a good therapeutic relationship. The practitioner of any CAM modality also needs to be aware in his therapeutic relationships that a patient might also easily get a wrong idea of the effectiveness. The patient in this case reserved time to check if acupuncture could help with Ménière’s disease when medicine failed. She had already had made the assumption that vertigo was because of Ménière’s disease and that acupuncture might help. Currently, there is preliminary evidence that acupuncture might work for Ménière’s disease (He et al. 2016) but her expectations were high because of the previous success with uveitis. It is sometimes almost impossible to avoid giving false hope by just agreeing to treat any less commonly treated symptoms. Not treating or overly explaining that the treatment might not work might harm the therapeutic relationship and even prevent the referral to a doctor in case it is needed.

Reflecting upon therapeutic relationships and clinical skills after this incident, the author became more aware of possible consequences of his therapeutic practice. It would be unrealistic to think that these mistakes couldn’t ever happen in the future, but there are always ways to improve the practice. He will now reserve extra time for returning patients if a few years have passed from the last session. With this he tries to ensure that he has enough time to collect information. Even in cases of seemingly minor complaints that do not respond to acupuncture treatments, the patients will from now on be routinely encouraged to see a doctor upon termination of the course of treatment. Before, the patients have already been asked to see doctor if there have been any alarming symptoms, but minor health concerns might have been previously overlooked. The author himself sees the work of an acupuncturist very tightly interwoven with the medical profession and sees further cooperation between different medical modalities as a requirement for patient safety. The author also concludes that it is unlikely that offering acupuncture would generally cause delays in diagnosis and treatment of a serious disease like cancer, but there is definitely a lack of proper studies in this area.

 

References

Chiu, HY., Hsieh, YJ. and Tsai, PS. (2017) Systematic review and meta-analysis of acupuncture to reduce cancer-related pain. European Journal of Cancer Care. 2017 Mar;26(2).

Duong, N., Davis, H., Robinson, PD., Oberoi, S. Et al. (2017). Mind and body practices for fatigue reduction in patients with cancer and hematopoietic stem cell transplant recipients: A systematic review and meta-analysis. Critical Reviews in Oncology/Hematology. 2017 Dec;120:210-216.

Eardley, Susan., Bishop, a Felicity L., Prescott, Philip. Et al. (2012) A Systematic Literature Review of Complementary and Alternative Medicine Prevalence in EU. Forsch Komplementmed 2012;19(suppl 2):18–28

Eisenberg, David M., Kessler, Ronald C., Van Rompay, Maria I. Et al. (2001). Perceptions about Complementary Therapies Relative to Conventional Therapies among Adults Who Use Both: Results from a National Survey. Annals of Internal Medicine. 2001 Sep 4;135(5):344-51.

Hamilton WL., Doyle C., Halliwell-Ewen M., Lambert G. (2016) Public health interventions to protect against falsified medicines: a systematic review of international, national and local policies. Health Policy Plan. 2016 Dec;31(10):1448-1466.

He, Jiaojun., Jiang, Liyuan., Peng, Tianqiang. et al. (2016). Acupuncture Points Stimulation for Meniere’s Disease/Syndrome: A Promising Therapeutic Approach. Evidence-Based Complementary and Alternative Medicine. 2016. Article ID 6404197

Houzé B., El-Khatib H., Arbour C. (2017) Efficacy, tolerability, and safety of non-pharmacological therapies for chronic pain: An umbrella review on various CAM approaches. Progress in Neuropsychopharmacology & Biological Psychiatry. 2017 Oct 3;79(Pt B):192-205.

Hu, Caiqiong., Zhang, Haibo.,Wu, Wanyin. Et al. (2016) Acupuncture for Pain Management in Cancer: A Systematic Review and Meta-Analysis. Evidence-Based Complementary and Alternative Medicine. Volume 2016, Article ID 1720239.

Jakes, Dan., Kirk, Ray. and Muir, Lauretta. (2014). A Qualitative Systematic Review of Patients’ Experiences of Acupuncture. The Journal of Alternative and Complementary Medicine, 20(9):663–671

Kim, Me-Riong., Shin Joon-Shik, Lee Jinho Lee, Lee Yoon Jae et al. (2016). Safety of Acupuncture and Pharmacopuncture in 80,523 Musculoskeletal Disorder Patients: A Retrospective Review of Internal Safety Inspection and Electronic Medical Records. Medicine. 95(18):e3635, MAY 2016.

Lipsitt, Don R., Joseph, Robert. Meyer, Donald. and Notman, Malkah T. (2015) Medically Unexplained Symptoms: Barriers to Effective Treatment When Nothing Is the Matter. Harvard Review of Psychiatry. 2015 Nov-Dec;23(6):438-48

MacArtney, John I. and Wahlberg, Ayo. (2014). The Problem of Complementary and Alternative Medicine Use Today: Eyes Half Closed?. Qualitative Health Research 2014, Vol. 24(1) 114–123.

Mcculloch M., Nachat A., Schwartz J., Casella-Gordon V. and Cook J. (2015). Acupuncture safety in patients receiving anticoagulants: a systematic review. Permanente Journal. 2015 Winter;19(1):68-73.

Ng JY., Liang L. and Gagliardi AR. (2016) The quantity and quality of complementary and alternative medicine clinical practice guidelines on herbal medicines, acupuncture and spinal manipulation: systematic review and assessment using AGREE II. BMC Complementary and Alternative Medicine. 2016 Oct 29;16(1):425.

Park J., Sohn Y., White AR. and Lee H. (2014). The safety of acupuncture during pregnancy: a systematic review. Acupuncture in Medicine: Journal of the British Medical Acupuncture Society. 2014 Jun;32(3):257-66.

Potential Signals of Serious Risks/New Safety information identified from the FDA Adverse Event Reporting System. FDA Adverse Event Reporting System (FAERS) Public Dashboard. https://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/Surveillance/AdverseDrugEffects/ucm070093.htm (Last accessed 30.7.2018)

Rankin, Nicole M., York, Sarah., Stone, Emily. Et al. (2017). Pathways to Lung Cancer Diagnosis: A Qualitative Study of Patients and General Practitioners about Diagnostic and Pretreatment Intervals. Annals of the American Thoracic Society. 2017 May;14(5):742-753

Salminen, Kaisa. (2018) Potential metabolism-based drug interactions with isoquinoline alkaloids: an in vitro and in silico study. Publications of the University of Eastern Finland. Dissertations in Health Sciences., no 444.

Shorofi, Seyed Afshin., Arbon, Paul. (2017). Complementary and alternative medicine (CAM) among Australian hospital-based nurses: knowledge, attitude, personal and professional use, reasons for use, CAM referrals, and socio-demographic predictors of CAM users. Complementary Therapies in Clinical Practice. 2017 May;27:37-45.

Turner LA., Singh K., Garritty C., Tsertsvadze A. et al. (2011). An evaluation of the completeness of safety reporting in reports of complementary and alternative medicine trials. BMC Complementary and Alternative Medicine. 2011 Aug 22;11:67.

Warnock, Rory., Jeffries, Owen., Patterson, Stephen and Waldron, Mark. (2017) The Effects of Caffeine, Taurine, or Caffeine-Taurine Coingestion on Repeat-Sprint Cycling Performance and Physiological Responses 2017 Nov 1;12(10):1341-1347.

Witt C.M., Pach D., Brinkhaus B., Wruck K. et al. (2009). Safety of Acupuncture: Results of a Prospective Observational Study with 229,230 Patients and Introduction of a Medical Information and Consent Form. Forsch Komplementmed 2009;16:91–97.

Wu, Xinyin., Chung, Vincent CH., Hui, Edwin P. et al. (2015). Effectiveness of acupuncture and related therapies for palliative care of cancer: overview of systematic reviews. Scientific Reports. 2015 Nov 26;5:16776.

Zhang, Y., Lin, L., Li, H. et al. (2018). Effects of acupuncture on cancer-related fatigue: a meta-analysis. Support Care Cancer. 2018 Feb;26(2):415-425.

Zick, Suzanna M., Sen, Ananda., Wyatt, Gwen K. et al. (2016). Investigation of 2 Types of Self-administered Acupressure for Persistent Cancer-Related Fatigue in Breast Cancer Survivors: A Randomized Clinical Trial. JAMA Oncology. 2016 Nov 1;2(11):1470-1476.

Chinese & East Asian Medicines, Religion & Medicine

Daoist Contemplation and Chinese Medicine, Part 1: History and definition of contemplation in Daoist texts

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Different forms of contemplative practices have been one of the key elements in Daoist tradition. This essay will appear in four parts dealing with:

1. History and definition of contemplation in Daoist texts

2. Contemplative practices and concept of body-mind

3. Contemplation and dietary practices

4. Contemplation and art of medicine

In these short essays I define contemplative practices, look historical relevance and how has it affected the development Chinese medicine and what does it has to do with ideals of art of medicine. Some concepts presented might no longer fit to current understanding of Chinese medicine, but they have played consequential role in formulation of ideas and have been influential cultural context for ancient doctors who wrote some of the foremost classics of Chinese medicine. While reading these essays please keep in mind, that heart and mind are same word (xīn 心) in Chinese.

Defining Daoist contemplation

To be able to track down history of contemplative practices we first need to be able to define what we mean by contemplation. Modern practitioners usually prefer to use trendy terms like mindfulness often defined as conscious awareness and non-judgmental acceptance. While this might work well for some forms of practices, for more historical study we have to to rely on Daoist and Chinese Buddhist terms, definitions and context.

Mindfulness research literature often takes terms sati (Pāli) and smṛti (Sanskrit), which directly translates to Chinese niàn 念, to mean contemplation and mindfulness. Niàn means memory or recollection; to think on or to reflect upon something; to read or study. In Daoist context this term can be used for studying scriptures and contemplating or holding an object or idea in mind. Sometimes this is done by concentrating on a deity.

However, most of the Daoist texts use term guān 觀 in Chinese literature. It translates to looking and observing. Very often it is used in connection with word nèi 內 which means inner or internal to denote the nature and direction of observation. Therefore nèiguān 內觀 could be translated as inner observation. Nèiguān also serves as literal translation of Buddhist concepts of vipassanā (Pāli or vipaśyanā in Sanskrit). Inner contemplation or nèiguān is set of practices where one directs his awareness within himself. In different types and stages of the practice object of awareness can be body as whole or some part like an organ. Object can be an emotion and how it is experienced within body-mind in level qì or energy. Many of these techniques concentrate on breathing. Some of the breathing meditations are similar to what is described in Buddhist Ānāpānasati Sutta (Pāli) or Ānāpānasmṛti Sūtra (Sanskrit). However Daoist practitioners often start their practice by concentrating on subtleties of breathing felt on lower abdomen instead the mindfulness of breathing itself.

The aim of contemplation has usually been, especially in Daoist practice, to be able to slowly shift ones attention to mind itself. This is usually seen as the key element of the practice in Daoist context as the “real” contemplation is apophatic in nature, striving to attain total emptiness and complete negation or detachment from desires, concepts and contents of the mind. This emptiness is obtained by silencing the mind with sustained non-interfering observation or Nèiguān. The famous Qīngjìngjīng 清靜經 explains:

能遣之者,内觀於心,心無其心;外觀於形,形無其形;遠觀於物,物無其物。三者既悟,唯見於空。觀 空以空,空無所空。所空既無,無無亦無。無無既無,湛然常寂。寂無所寂,慾豈能生?慾既不生, 即是真靜。

“These [desires] can be removed by internally contemplating the heart (mind). The heart is not this heart. Externally contemplating form. The form is not this forms. From distance contemplating things. These things are not these things. After these three have been realized and [you are] just seeing these as emptiness, contemplate this emptiness with emptiness. Emptiness does not exists in emptiness. In [this] emptiness there is still [further] non-existence. Non-existence of non-existence is also non-existing. [When] non-existence of non-existence is non-existing, there is deepest and eternal stillness. In stillness [where even] stillness does not exists, how could desires arise? When desires cannot arise, it is true peace.”

Despite the epilogue by Gě Xuán 葛玄 (164–244) who attributed the text to goddess Xīwángmǔ 西王母, in reality the text is probably written during early Tang-dynasty (618 – 907)[1]. The wording is clearly influenced by Buddhism but it gives the essential idea about contemplative practice and its apophatic nature. Following this nature we can start tracing contemplative practices through history. This nature is crucial for understanding continuation of the practice, its ideals and importance to Chinese medical and philosophical culture.

Early views and history of contemplative practices in China

Nèiguān practices that flourished in China during Tang-dynasty (618 – 907) are usually thought to have their origin in Buddhism. Buddhism started spreading to China during the 2nd century CE and one of the most well known Buddhist missionaries during the time was Ān Shìgāo 安世高 (c. 148 – 180) who translated Buddhist texts to Chinese language[2]. Among these texts there was also Ānāpānasati Sutta containing outlines of same idea used in practice of nèiguān. But even before that the practice was already well known in China. One of the oldest and synonymous expression to nèiguān is kǎonèishēn 考內身 which can be found from scripture titled Báixīn 白心 or Purifying the mind. In Báixīn there is a passage which says:

欲愛吾身,先知吾情君親六合,以考內身。以此知象,乃知行情既知行情,乃知養生。

“Desires and affections [arise from] our own body. First we understand our emotions, ruling sentiments and six harmonies by looking inside the body. Then we’ll know images after which we understand movement of emotions. By knowing movement of emotions we then understand cultivation of life (yǎngshēng).”

I translate kǎonèishēn here as looking inside the body. It might have been more easily understood by Western readers of spiritual practices, if I had translated it to inspecting inner bodies but that might be a bit stretching for context of early Daoist texts. Therefore the word body (shēn 身) needs bit clarification. The view of body in many archaic Chinese texts was much more broad than our modern use of the word. It was not just torso with four limbs but more a vessel composed of and containing different energies, spiritual influences and essence (jīng 精). It was seen intimately connected to time and world around us. I’ll come back to nature of body-mind in next part but the important thing here is that Báixīn gives advice to turn our attention into our body-minds to become aware of emotions and mental images. Báixīn also belongs to the earliest texts using term yǎngshēng or cultivating life which later formed a central concept in many medical and religious practices.

Báixīn dates back to 285 – 235 B.C. being from last period of Jìxià Academy (Jìxià xuégōng 稷下學宮)[3]. It is included in collection of political and philosophical texts named Guǎnzǐ 管子. The collection contains three other meditative texts namely Xīnshù shàng 心術上, Xīnshù xià 心術下 and Nèiyè 內業. Both Xīnshù texts speak of emptiness of the heart or mind. “Empty it (mind) from desires and Shén (Spirit) enters its domain. Clean from impure and Shén will remain in its place.” (《心術上》：虛其欲,神將入舍。掃除不潔,神乃留處。)

Xīnshù texts expand the ideas presented in older text called Nèiyè and transform individual meditation practice to fit the fields of economics and politics. They advocate importance of contemplative mindfulness practice to rulers and bureaucrats. The ideal ruler must remain detached from confusion of emotions and doubts. Their mind must remain clear in order to rule efficiently. Xīnshù xià states that:

心安,是國安也。心治,是國治也。… 治心在於中,治言出於口,治事加於民;故功作而民從,則 百姓治矣。

“When mind is peaceful nation is at peace. When mind is governed nation is [under] governance…When governed mind stays at its center and controlled words come out of mouth then governed actions are guiding the subjects. Thus good results are achieved and people will follow. In this way the common people are governed.”

Many texts from Huáng-Lǎo School promote contemplation to gain understanding of laws of governing people and contemplation was seen as a mean to understand universal way or law which also controlled the society. This discourse is highly interesting when we compare it to modern mindfulness movement and especially mindful leadership where we see similar claims and uses. Meditative texts of Guǎnzǐ do not demand worship, divination or other ritualistic techniques. They are plain and simple self cultivation practices written by the literati to other members of ruling class of their time. The fact that these texts were included in highly political text collection gives us an impression that these practices were wide spread and not known only in religious circles. This is especially evident as many of the texts in Guǎnzǐ belong to strict Legalist school that saw tradition and softer values as weakness to be cut down[4].

The Guǎnzǐ collection also includes scripture called Nèiyè 內業 or Internal practice, which is probably the oldest of surviving Chinese meditation manuals and dates back to circa 325 B.C. The poetic style of Nèiyè suggests oral tradition and therefore even older origin.[3] Nèiyè presents very clear and plain description of meditation. Its themes are similar to many Tang-dynasty meditation texts and Nèiyè defines connection of man to universe, reason for contemplation, different attitudes and key elements for practice. The text begins with idea how human being is connected to cosmos:

凡物之精,比則為生下生五穀,上為列星。流於天地之間,謂之鬼神,藏於胸中,謂之聖人。

“From the essence of every being comes their life. Below it gives birth to five grains, above forms the constellations. Its flow between heaven and earth we call as spirits and gods. When it is stored within center of chest we call him a sage.”

During writing of Nèiyè the idea of essence (jīng 精) was still developing. The essence was seen as something having nature of divinity or spirit. Later it became described more substantial and bit liquid like as in texts like Huángdì Nèijīng Sùwèn 黃帝內經素問. The concept of Jīng-Shén 精神, which is usually translated as life-force or vigor it still retained its early intangibility. Some of the early texts see essence as one of the “bodily spirits” or shén.

The text proceeds defining how all the sorrows arise from the heart and they are ended with the heart. The heart was seen to effect everyone around us, bringing with it our fortunes or misfortunes. Only cultivation of the heart was seen as means for real moral development and thus Nèiyè states that:

賞不足以勸善,刑不足以懲過。氣意得而天下服。心意定而天下聽。

“Rewards are not sufficient to encourage virtue, nor punishments enough for disciplining. [Only] when qi-mind is obtained, that what is under the heaven will be subjugated. Only when heart-mind is stopped that what is under the heaven will obey.”

Same idea of shedding false morals, ethical values and empty rituals and replacing them by true nature was recurring theme in even earlier Zhuāngzǐ 莊子.

Author(s) of Nèiyè also pondered how or what in the mind can observe itself:

何謂解之,在於心安。我心治,官乃治。我心安,官乃安。治之者心也,安之者心也;心以藏心,心之中又有心焉。彼心之心,音以先言,音然後形,形然後言。言然後使,使然後治。不治必亂,亂乃死。

“How to explain that which is in peaceful heart? [When] I (ego) and heart are regulated, officials (organs) are regulated. [When] I and heart are at peace, officials are in peace. One regulating them is heart. One pacifying them is heart. There is heart hidden within heart. In the center of the heart there is another heart! This heart within heart is the voice before the words. From the voice follow forms, from the form follow the words. From the words follow actions and from the actions follow governing. [From that which] is not governed follows chaos and from the chaos follows death.”

As non-controlled mind was seen as main reason for chaos and destruction the often emphasized benefit from cultivation was freedom from internal conflict and outer catastrophes. In Nèiyè this freedom is describes thus:

中無惑意,外無邪菑,心全於中,形全於外。不逢天菑,不遇人害,謂之聖人。

“Without confusing thoughts within, one is externally without evil and disasters. Heart maintained in the center and form is maintained externally. [Thus one does] not encounter heavenly calamities nor face human troubles [therefore] we call him a sage.”

Freedom from human suffering later became exaggerated more and more until it became immortality and total untouchability during Han-dynasty and was still aim of contemplative practitioners during Tang-dynasty. See for example text called Preserving Shén and refining Qì.
The themes of freedom, emptiness and cultivation of heart were also present in many other writings of the time, but were often less instructive and more ambiguous in their poetic or prosaic expression. Of these texts Dàodéjīng 道德經 and Zhuāngzǐ are famous examples. Zhuāngzǐ for example describes fasting of the heart in following quote:

回曰:「敢問心齋。」仲尼曰:「若一志,无聽之以耳而聽之以心,无聽之以心而聽之以氣。聽止於耳,心止於符。氣也者,虛而待物者也。唯道集虛。虛者,心齋也。」

“[Yán] Huí said: Could I ask about fasting of mind?
Zhòng Ní answered: When having singular will, you’ll not hear with ears but you hear them with heart. When not hearing with heart you’ll hear them with qì. Hearing stops to listening with ears. Heart stops to symbols. The Qì is emptiness that receives things. Only Dào gathers in emptiness. Emptiness is fasting of the heart.”

Dàodéjīng as the best known Daoist text has collected many different translations around it. The text describes contemplation in its 16th chapter:

致虛極,守靜篤。萬物並作,吾以觀復。夫物芸芸,各復歸其根。歸根曰靜,是謂復命。復命曰常,知常曰明。不知常,妄作凶。知常容,容乃公,公乃天,天乃道,道乃久,沒身不殆。

“Reaching the utmost emptiness and guarding stillness and honesty, 10 000 things are working in union. Contemplating this, I’ll return. Countless humans and beings all return to their root. Returning to the root is called stillness. It is also described as returning to life (fù mìng is literally returning the destiny). Returning to life is called eternity. Knowing eternity is called enlightenment. Not knowing eternity [you just] arrogantly cause disasters. By knowing eternal you’ll accept. From accepting follows fairness. From fairness follows completion. From completion follows heavenly and from heavenly follows Dào. From Dào follows continuation and [then even] disappearance of body is not fatal.”

Considering this particular chapter we have to take into account that Dàodéjīng, as we now read it, was edited by Wáng Bì during early third century. The chapter found from the Mǎwángduī excavation, dating to second century B.C.[5] is very similar but a century older Guōdiàn[6] version does not mention contemplation at all. The importance of observing with empty mind is prominent in many other chapters as well.

Taking into account textual evidence about these contemplative practices and the idea of using them for returning to original state or to finding true nature had clearly been already developed before end of Warring States period. The Chinese still remained isolated from India centuries after writing the meditative texts of Guǎnzǐ or Dàodéjīng and Zhuāngzì. It was only at the first and second centuries during which trading of goods and thoughts between China and India really begun. If we consider the possible dating of historical Buddha to be somewhere around the commonly agreed 566–486 B.C.[7], it is hardly likely that Buddhist influence at the time could have induced such a wide spread of contemplative ideology in China. Buddhist tradition speaks of teachers Ārāḍa Kālāmalta ja Uddaka Rāmaputta as well reputed teachers, so we can say that these practices were also more wide spread in India during that time. But with lack of active trade routes, cultural exchange and having textual sources showing more wide spread cultural use of the contemplative ideas in China, we may conclude that it is highly likely that contemplative practices were developed independently in China and the Buddhist influences merged to Chinese contemplative ideologies and practices only later.

Rise of Buddhism in China however sparked new interest in contemplative practices. Old texts were edited, new texts were written and older classics were interpreted from viewpoint more fitting to contemplative practices. Zuòwàng lùn 坐忘論, which quotes heavily on Dàodéjīng and Zhuāngzǐ, is good example of reinterpreting older scriptures. The spread of Buddhism also influenced other areas of practices like dietary taboos and ethical codes. What remained the same was apophatic nature of contemplative practice. To quote a Tang-dynasty text called Nèiguānjīng 內觀經 – Classic of inner contemplation:

道也者,不可言傳口授而得之。常虛心靜神,道自來居。

“Dào cannot be put to words. By mouth it cannot be given or obtained. [By having] constantly empty heart and tranquil spirit, Dào naturally returns to its residence.”

 

References

  1. Verellen Franciscus and Schipper Kristofer. The Taoist Canon: A Historical Companion to the Daozang. University Of Chicago Press, 2005.
  2. Greene Eric M. Healing breaths and rotting bones: On the relationship between buddhist and chinese meditation practices during the eastern han and three kingdoms period. Journal of Chinese Religions, 4(2):145–184, 3 2014. (www)
  3. Roth Harold D. Daoism in the guanzi. In book Liu Xiaogan (editor), Dao Companion to Daoist Philosophy, pages 265–280. Springer, 2015.
  4. Rickett Allyn W. Guanzi: Political, Economic, and Philosophical Essays from Early China. Princeton University Press, 1998.
  5. Harper Donald. Early Chinese Medical Literature. Routledge, 1997.
  6. Meyer Dirk. Meaning-Construction in Warring States Philosophical Discourse: A Discussion of the Palaeographic Materials from Tomb Guōdiàn One. Doctoral thesis, Leiden University, 2008. (www)
  7. Heinz Bechert, editor. The Dating o fthe Historical Buddha. Die Datierung des Historischen Buddha. Symposien zur Buddhismusforschung, IV, 1, 1991. (www)