PractisingNon-Evidence-BasedMedicine:

EthicalIssuesinthePracticeofTraditionalChineseMedicineinCanada

WinnieFok

FacultyofPhilosophy

SaintPaulUniversity

May2018

AthesissubmittedtotheDepartmentofGraduateStudiesinpartialfulfillmentofthe

requirementsfortheMasterofArtsdegreeinPublicEthics.

©WinnieFok,Ottawa,Canada,2018

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TableofContents

Abstract ....................................................................................................................................................3Disclosure................................................................................................................................................4Preface......................................................................................................................................................5Acknowledgements ........................................................................................................................................6

Introduction............................................................................................................................................7I.OverviewofTCMPractice............................................................................................................ 11TCMRegulationinCanada ........................................................................................................................ 11TCMCharacteristics .................................................................................................................................... 14TCMEthicalFrameworks .......................................................................................................................... 19TCMisNon-Evidence-BasedMedicine .................................................................................................. 23

II.RespectforAutonomy................................................................................................................. 31SurveyMethodology.................................................................................................................................... 32SurveyResearchEthics(REBFileNumber:1360.6/17) ................................................................. 35SurveyParticipants ..................................................................................................................................... 37

Table1:DemographicData(n=17) .......................................................................................................................... 38SurveyFindingsandInterpretation ...................................................................................................... 40

Table2:AwarenessofTCMasnon-EBMandFrequencyofUsingTCM(n=17) ...................................... 40Table3:AnswersfromGroupA(participantswhohavemoreexperienceofusingTCMn=13) ...... 42Table4:AnswersfromGroupB(participantswhohavelessexperienceofusingTCMn=5) ............ 43Table5:AwarenessofTCMasnon-EBMandtheCorrespondingRankingsof“Beneficence”,“Justice”and“Nonmaleficence”(n=17) ................................................................................................................................... 45Table6:Rankingsof“Beneficence”,“Justice”and“Nonmaleficence”ofAllParticipants(n=17) ..... 47

ConclusionsoftheSurvey ......................................................................................................................... 47III.BeneficenceandNonmaleficence .......................................................................................... 50MoralCharacter............................................................................................................................................ 53Practitioner-PatientRelationshipModel............................................................................................. 57Teacher-ApprenticeLearningModel .................................................................................................... 61StudentSelection.......................................................................................................................................... 63IntensiveClinicalPractice......................................................................................................................... 67

IV.Justice .............................................................................................................................................. 71MedicareandInsuredHealthService ................................................................................................... 72ShouldTCMbeanInsuredHealthService? ......................................................................................... 78UtilitarianismandCost-BenefitAnalysis ............................................................................................. 81ValuesofEquity,FairnessandSolidarity............................................................................................. 86

Conclusion............................................................................................................................................ 92AppendixASurveyPackage ........................................................................................................... 96WorksCited ...................................................................................................................................... 103

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Abstract

TraditionalChineseMedicine(TCM)isnon-evidence-basedmedicine.Thepurposeofthis

thesisistoidentifyandaddresssomepotentialTCMethicalissuesthatareparticularly

relatedtonon-evidence-basedmedicine.InapplyingBeauchampandChildress’sfour

principlesapproach(principlism),Iidentifythreepotentialethicalissuesinthepracticeof

TCMinCanada.ThefirstissuepertainstoenablingTCMpatientstomaketheinformed

decisionconcerningtheuseofTCM.ThesecondissuerelatestotheobligationofTCM

practitionerstodistinguishshamsfromeffectiveTCMtreatments.Thethirdissueconcerns

equalaccesstoTCMcareinthecontextoftheCanadaHealthAct.Afteridentifyingeach

issue,Iputforwardsuggestionstoaddressit.

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Disclosure

Theauthorisaself-employedRegisteredTCMPractitioner(R.Ac.,R.TCMP)inOntario.The

opinionsexpressedinthisthesisarethoseoftheauthoranddonotnecessarilyreflectthe

positionofotherindividuals,organizationsortheTCMprofession.

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Preface

IenterthisresearchasaTCMpractitioner.Thankstotheworkofotherscholarsand

practitioners,itisestablishedthatTCMisrecognizedasahealthcareprofessioninCanada.

IneednotdebatethevalueofTCMoritsrightfulplaceinhealthcareinthisthesis.

InBuildingonValues:TheFutureofHealthCareinCanada,RoyRomanowstatesthat

“Canadiansviewmedicareasamoralenterprise,notabusinessventure.”1Being

recognizedasahealthcareprofessionalinCanadaisaprivilegeandwithitcomesthe

responsibilitytoexercisemoralreasoninginourpractice.Mythesisintendstoaddress

somepotentialethicalissuesinthecontextofpracticingTCMinCanada.InTheMethodsof

Ethics,HenrySidgwickexplainsthat:

...thehistoryofMoralPhilosophy...wouldbeahistoryofattemptstoenunciate,in

fullbreadthandclearness,thoseprimaryintuitionsofReason,bythescientific

applicationofwhichthecommonmoralthoughtofmankindmaybeatonce

systematisedandcorrected.2

SidgwicksummarizesthemostprofoundlessonthatIhavelearnedfromstudyingpublic

ethics.Inwritingthisthesis,Istrovetopracticetheaboveapproachinformulatingmy

1RoyJ.Romanow,BuildingonValuestheFutureofHealthCareinCanada:FinalReport(Saskatoon,Sask.:CommissionontheFutureofHealthCareinCanada,2002),xx,https://login.proxy.bib.uottawa.ca/login?url=http://books.scholarsportal.info/viewdoc.html?id=/ebooks/ebooks0/gibson_cppc/2009-12-01/6/207365.2HenrySidgwick,TheMethodsofEthics,6thed.(London;NewYork:MacMillanandCo.Limited;TheMacmillanCompany,1901),413–14,http://tinyurl.galegroup.com/tinyurl/4YWos4.

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thoughts.Myuseofempiricaldataandpersonalexperienceisforthepurposeofreasoning.

Thereisnointentiontodivulgeanyprivilegedinformation.

Acknowledgements

In2015,IequippedmyselfwithinadequatecredentialstoapplyfortheMasterofArtsin

PublicEthicsProgram.MygratitudetoAmyandPaulfortheirsupportintheprocess.Iam

gratefulfortheconditionaladmissionatSaintPaulUniversity.IshallputwhatIlearnhere

togooduseforsociety.

Iamindebtedtomysupervisor,Dr.MoniqueLanoixforhersupportinwritingthisthesis.

Sheisgenerousinsharingherideasandkeepsmefocusedonworthyresearch.Without

herguidance,Iwouldnothaveorganizedorexpressedmythoughtsproperly.

MythankstoDr.RajeshShukla,Dr.RichardFeistandDr.MatthewMcLennanfortheir

interestingcoursesinmoraltheoriesandappliedethics.Iwasinspiredtowritearesearch

thesisbecauseoftheirwisdomandencouragement.

Totheparticipantsintheempiricalstudyofthisthesis,thankyoufortheinput.Thethesis

wouldmeanverylittlewithoutyourinterestinTCM.

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Introduction

TCMisnotrecognizedasevidence-basedmedicineandhence,itisconsideredasnon-

evidence-basedmedicineforthepurposeofthisthesis.Non-evidence-basedmedicineis

nottheequivalentofmedicinewithnoevidence3astherearedifferentlevelsofevidence4.

Nevertheless,beingnon-evidence-basedmedicineimpliescertainclinicalrealitiesand

constraints.Therearepotentialethicalissuesforpractitionersaswellaspatients.The

purposeofthisthesisistoidentifyandaddresssomeofthepotentialethicalissuesthatare

facingTCMpractitioners.IapplyBeauchampandChildress’sfourprinciplesapproach

(principlism)astheinitialethicalframeworktoidentifythreeissues.Thefirstissue

pertainstoenablingTCMpatientstomakeaninformeddecisionregardingtheuseofTCM.

ThesecondissuerelatestothedifficultyandobligationofTCMpractitionerstodistinguish

shamsfromeffectiveTCMtreatments.ThethirdissueconcernsequalaccesstoTCMcarein

thecontextoftheCanadaHealthAct.Afteridentifyingeachissue,Iputforwardsuggestions

toaddressit.

PrinciplismisacommonethicalframeworkinWesternbiomedicine.Itisgroundedinwhat

BeauchampandChildresscall“commonmoralitytheory”andusesfourprinciples:respect

3IzetMasic,MilanMiokovic,andBelmaMuhamedagic,‘EvidenceBasedMedicine–NewApproachesandChallenges’,ActaInformaticaMedica16,no.4(2008):219–25,https://doi.org/10.5455/aim.2008.16.219-225.4‘OxfordCentreforEvidence-BasedMedicine-LevelsofEvidence(March2009)’,CEBM,11June2009,https://www.cebm.net/2009/06/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/.

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forautonomy,beneficence,nonmaleficenceandjusticeasthestartingpointforbiomedical

ethics.5IacceptBeauchamp’sclaimthatitisatheoryandpracticalmethodforcliniciansto

yieldpracticaljudgementsinbioethics6.Therefore,principlismistheethicalframeworkto

identifyethicalissuesinthisthesis.

Themaincontentofthisthesisisorganizedintofoursections.SectionIisanoverviewof

TCMpracticeinCanada.SectionII,“RespectforAutonomy,”sectionIII,“Beneficenceand

Nonmaleficence,”andsectionIV,“Justice,”arenamedaftertheethicalprinciplesthat

identifytheissues.InadditiontomyTCMtraining,Ireviewedavarietyofbooksand

journalarticlesrelatedtoChinesemedicine,bioethics,evidence-basedmedicine,

qualitativeresearch,ethicseducation,cost-benefitanalysisandmedicare.Theliterature

wasaccessedmainlythroughtheUniversityofOttawalibrary.Ialsoreferredtoseveral

onlinecoursesonedx.orgtofurthermyunderstandingofrandomizedclinicaltrialsand

Chinesephilosophy.TheinformationrelatedtoTCMregulationsorCanadaHealthActis

basedonthepublicwebsitesofTCMassociations,TCMregulatorsandHealthCanada.

SectionIdescribeshowTCMisregulatedinCanada,introducessomeTCMcharacteristics,

highlightsthemainethicalframeworksforTCMpractitionersandexplainswhyTCMisnot

recognizedasevidence-basedmedicine.Itfollowsthatsomepotentialethicalissues

deserveourattention.

5TomL.Beauchamp,PrinciplesofBiomedicalEthics,7thed..(NewYork:OxfordUniversityPress,2013),Ch.1.6TomL.Beauchamp,‘TheTheory,Method,andPracticeofPrinciplism’,16July2015,1,https://doi.org/10.1093/oxfordhb/9780198732365.013.31.

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SectionIIpertainstoenablingTCMpatientstomakeaninformeddecisiontouseTCM.This

sectionfocusesonanempiricalstudyintheformofaquestionnairesurvey.Thepurposeof

thesurveyistogaugetheawarenessofTCMbeingnon-evidence-basedmedicineamong

theparticipantsanditsimpactontheirdecisionstouseTCM.Thefindingsalsosuggest

someTCMpatientcharacteristicsamongtheparticipants.Theresultsarequalitativewith

nostatisticalpowertomakegeneralization.TheempiricalstudywasapprovedbytheSaint

PaulUniversityResearchEthicsBoard(REBFileNumber:1360.6/17)beforedata

collection.SectionIIdiscussesthemethodology,ethicsreview,resultsandinterpretationof

thestudyindetails.AppendixAincludesacopyoftheResearchEthicsBoardapproval

certificateandthefullpackageofthesurveyinvitation.

SectionIIIrelatestothedifficultyandobligationofTCMpractitionerstodistinguishshams

fromeffectiveTCMtherapies.ThesafetyandefficacyofTCMinCanadarelyontheethical

standardsandcompetencyofTCMpractitioners.Emphasisonmoralcultivationandthe

idealmodelofpractitioner-patientrelationship7inTCMtrainingcaneffectivelypromote

highTCMstandardsofpracticeforthelongterm.Isuggestexploringtheteacher-

apprenticelearningmodelinTCMtraininginordertofacilitatesuchanendeavour.

SectionIVconcernstheissueofequalaccesstoTCMcareinthecontextoftheCanada

HealthAct.AfterprovidinganoverviewofCanada’spublichealthcaresystem(medicare)

andtheinsuredhealthservice,IaskifTCMshouldbeincludedinthecoverage?Cost,

7EzekielJ.EmanuelandLindaL.Emanuel,‘FourModelsofthePhysician-PatientRelationship’,JAMA267,no.16(22April1992):2221–26,https://doi.org/10.1001/jama.1992.03480160079038.

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benefitandthefoundingvaluesofmedicare(equity,fairnessandsolidarity)areprominent

factorsinCanada’smedicarepolicy.Iexplorewhetherutilitarianismandthevaluescan

shedlightonthequestionofTCMcoverageinmedicare.

Toconcludemythesis,Isummarizealltheresearchfindingsandsuggestionsfromsections

II,IIIandIVinthefinalchapter.Theconclusionalsoincludesalistofresearchareasthat

areworthyoffurtherinvestigationinCanada.

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I.OverviewofTCMPractice

ThefollowinginformationaboutTCMisrelevanttothesubsequentdiscussionsinmy

thesis.Itisorganizedundertheheadingsofregulation,characteristics,ethicalframework

andnon-evidence-basedmedicine.

TCMRegulationinCanada

InCanada,therearefiveprovincesthatregulateTCMundertheprovinciallegislation.

TheseprovincesareBritishColumbia,Alberta,Ontario,QuebecandNewfoundlandand

Labrador.TopracticeTCMlegallyintheseprovinces,onemustregisterwiththeregulator

oftheprovinceoftheirpractice.Thetablebelowliststheregulatorsforeachprovince:

BritishColumbiaCollegeofTraditionalChineseMedicinePractitionersandAcupuncturistsofBritishColumbia(CTCMA)

https://ctcma.bc.ca

Alberta CollegeandAssociationofAcupuncturistsofAlberta(CAAA) http://acupuncturealberta.ca

OntarioCollegeofTraditionalChineseMedicinePractitionersandAcupuncturistsofOntario(CTCMPAO)

http://www.ctcmpao.on.ca

Quebec OrderofAcupuncturistsQuebec(OAQ) http://www.o-a-q.org

NewfoundlandandLabrador

CollegeofTraditionalChineseMedicinePractitionersandAcupuncturistsofNewfoundlandandLabrador(CTCMPANL)

http://ctcmpanl.ca

Source:http://www.cmaac.ca/public/tcm-regulation-in-canada8

8‘TCMRegulationinCanada|C.M.A.A.C.–PromotionTCMandAcupuncture’,accessed28September2017,http://www.cmaac.ca/public/tcm-regulation-in-canada.

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Together,thesefiveregulatorsformTheCanadianAllianceofRegulatoryBodies–

TraditionalChineseMedicinePractitionersandAcupuncturists.Theallianceisresponsible

forensuringthecompetencyrequirementsforthepracticeofTCMinCanada.Thealliance

alsodesignsthenationalPan-CanadianExaminationandClinicalCase-StudyExaminations

forallTCMstudentgraduates.Inordertobeeligiblefortheexaminations,anapplicant

mustmeettheminimalTCMtrainingrequirement.Theprerequisitesforbeingqualifiedto

writethePan-CanadianExaminationsvaryfromprovincetoprovince.Ingeneral,

applicantsfortheregistrationofAcupuncturistarerequiredtohaveaminimumof1900

hoursofTCMeducationincludingbetween450and600hoursofpracticalclinicaltraining

inthreeacademicyears;andtheapplicantsfortheregistrationofTCMPractitionerare

requiredtohavecompletedaminimumof2600hoursoftraditionalChinesemedicine

programwithatleast650hoursofpracticalclinicaltraininginfouracademicyears.9, 10All

TCMregistrationapplicantsarerequiredtopasstheirrelevantPan-CanadianExaminations

beforebeingeligibletoregisterwiththeprovincialregulatorfortheprotectedtitles,such

asRegisteredAcupuncturists(R.Ac.)orRegisteredTCMPractitioner(R.TCMP),within

theirprovinceofpractice.

Similartootherhealthcareprofessionssuchasdentistryornursing,theTCMprofessionis

self-regulated.Self-regulationmeansthattheprovincialgovernmenthasmadealegislative

statute.Forexample,inOntario:thestatuesaretheRegulatedHealthProfessionsAct,1991

andTraditionalChineseMedicineAct,2006.Thesestatutesgiveagoverningbodytheduty9‘TCMRegulationinCanada|C.M.A.A.C.–PromotionTCMandAcupuncture’.10‘EducationProgramReview|CTCMA-CollegeofTraditionalChineseMedicinePractitionersandAcupuncturists’,accessed23October2017,http://www.ctcma.bc.ca/resources/education-program-review/.

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toregulatetheTCMprofession.InOntario,thegoverningbodyistheCollegeofTraditional

ChineseMedicinePractitionersandAcupuncturistsofOntario.11TheBoardofDirectorsof

theCollegeestablishesthepoliciesoftheCollegeandoverseesitsadministration.The

mandateoftheCollegeistoservethepublicinterestbyensuringthattheTCMprofession

actshonestlyandcompetently.Unliketheroleofaprofessionalassociation,theCollege

doesnotservetheself-interestoftheprofessionnorcanitlobbythegovernmentonbehalf

oftheinterestsoftheprofession.12OtherprovincesthatregulatethepracticeofTCMalso

havetheirownstatutesandgoverningbodieswithsimilarroles.

AccordingtotheTraditionalChineseMedicineAct(2006)inOntario,“Thepracticeof

traditionalChinesemedicineistheassessmentofbodysystemdisordersthrough

traditionalChinesemedicinetechniquesandtreatmentusingtraditionalChinesemedicine

therapiestopromote,maintainorrestorehealth.”13Registeredpractitionersareauthorized

topracticethefollowing:

1.Performingaprocedureontissuebelowthedermisandbelowthesurfaceofa

mucousmembraneforthepurposeofperformingacupuncture.

2.CommunicatingatraditionalChinesemedicinediagnosisidentifyingabody

systemdisorderasthecauseofaperson’ssymptomsusingtraditionalChinese

11‘Regulations·CTCMPAOWebsite’,accessed6November2017,https://www.ctcmpao.on.ca/regulation/.12‘JurisprudenceCourse·CTCMPAOWebsite’,handbookp.4-5,accessed28October2017,https://www.ctcmpao.on.ca/applicant/jurisprudence-course/.13‘StandardsofPractice·CTCMPAOWebsite’,accessed31January2018,https://www.ctcmpao.on.ca/regulation/standards-of-practice/.

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medicinetechniques.14

TherearemultiplemodalitiesoftherapiesortreatmentinTCM.ThemostcommonTCM

treatmentmodalitiesinCanadaareherbaltherapyandacupuncture.Ingeneral,a

registeredacupuncturist(R.Ac)isqualifiedtopracticeacupuncture.AregisteredTCM

practitioner(R.TCMP)isqualifiedtopracticeacombinationofacupunctureandherbal

therapies.15

TCMCharacteristics

Theterms“TraditionalChineseMedicine”and“Chinesemedicine”refertothesamesystem

ofmedicineforthepurposeofthisthesis.InChina,theterm“traditional”isoftenomitted

whenreferringtoChinesemedicine.IntheWest,mostscholarsandpractitionersusethe

term“TraditionalChineseMedicine”torefertoChinesemedicine.16Taylorexplainsthat

“theterm‘TraditionalChineseMedicine’firstappearedduringthelatterhalfoftheyear

1955,anditappearedfirstnotinmedicaldocuments,butinpoliticalones.”17

14‘StandardsofPractice·CTCMPAOWebsite’,accessed5October2017,https://www.ctcmpao.on.ca/regulation/standards-of-practice/.15‘PublicRegisterSearch·CTCMPAOWebsite’,accessed4October2017,https://www.ctcmpao.on.ca/publicregistersrc/.16VolkerScheid,ChineseMedicineinContemporaryChinaPluralityandSynthesis,E-DukeBooksScholarlyCollection(Durham,NC:DukeUniversityPress,2002),3,https://login.proxy.bib.uottawa.ca/login?url=http://dx.doi.org/10.1215/9780822383710.17Kim Taylor, Chinese Medicine in Early Communist China, 1945-63: A Medicine of Revolution, Needham Research Institute Studies (London ; New York: RoutledgeCurzon, 2005), 84.

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Scheidpointsoutthat“theterm‘traditional’invokestheinappropriatesensethatChinese

medicineisunchangedorunchanging,neitherofwhichistrue.”18Indeed,the

contemporarypracticeofTCMisgroundedinmodernbiomedicalscience.Justasa

physicistneedstoknowengineeringsciencetobuildfunctionalmachines,aTCM

practitionerneedstoknowbiomedicalsciencetocareforahumanbody.AcompleteTCM

curriculumforTCMpractitionerstodayincludestudiesinsubjectssuchasanatomy,

microbiologyandtoxicology.19, 20Inclinicalpractice,TCMpractitionersneedtounderstand

someWesternbiomedicineinordertocooperateandcomplementconventionalmedicine

withappropriateTCMtherapies.TCMpractitionersalsoneedtocollaboratewithandrefer

patientstoWesternbiomedicineprofessionalsaccordingtopatientsituations.21

TheCollegeofTraditionalChineseMedicinePractitionersandAcupuncturistsofOntario

statesthat:

TraditionalChineseMedicine(TCM)wasoriginatedinancientChinaandhasa

historyofovertwothousandyears.InfluencedbyancientChinesephilosophy,

culture,andscienceandtechnology,ChinesemedicineusesthetheoryofYinand

18Scheid,ChineseMedicineinContemporaryChinaPluralityandSynthesis,3.19HKBU,‘BachelorofChineseMedicineandBachelorofScience(Hons)inBiomedicalScience’,accessed7November2017,http://scm.hkbu.edu.hk/en/education/undergraduate_programmes/bachelor_of_chinese_medicine_and_bachelor_of_science_Hons_in_biomedical_science/index.html.20OCTCM,‘AcupunctureSchool|’,Acupunctureschool|OntarioCollegeofTCMToronto,accessed7November2017,https://www.studytcm.ca.21‘StandardsofPractice·CTCMPAOWebsite’.

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YangandthetheoryofWuXingtoexplainthemechanismofbalancingthefunction

ofthebody.22

TCMtheoryisbasedonQiandteachesthathealthistheresultoftheinternalbalanceofYin

andYang.23ThedifferencesbetweenTCMandWesternbiomedicinearerootedinhow

medicalconditionsarerepresented.TCMoftenrepresentsamedicalconditionwitha

metaphor.Forexample,Westernbiomedicinerepresentstheconditionofaheadachein

termsofoveractivepainreceptorsorvasoconstrictionofcerebralbloodvessels,butinTCM,

a headacheis representedasasyndromesuchasWind-ColdorHyperactivityofLiverYang.

IntranslatingTCMfromthelogographicChineselanguagetothedescriptivelanguageof

English,manyTCMmetaphorsbecomenonsensicaldescriptionsformany.

Forexample,thesymbolofYinYangTheory isametaphorthatdepictstwoopposing

matterswhichco-existandareinterdependent.YinandYangtransformintoeachother.

Thisimpliesthatwithinahealthybodysystem,YinandYangdynamicallyrebalanceeach

otherandtransformfromonetoanother.InTCM,thismetaphorplaysanimportantrolein

guidingthechoiceofherbs,acupuncturemethods,exerciseordietsintherapy.Ifthe

translationofthelogoissimplydescribedasacirclewithhalfofitbeingblackcolourwith

awhitedotandtheotherhalfbeingwhitecolourwithablackdot,themetaphorislost.The

translationdoesnothaveanymeaningtoTCM.Theepistemologicalandontological

22‘AboutTCM·CTCMPAOWebsite’,accessed28September2017,https://www.ctcmpao.on.ca/public/about-tcm/.23ChangguoWu,BasicTheoryofTraditionalChineseMedicine,ed.WuGuochang(Shanghai:ShanghaiCollegeofTraditionalChineseMedicinePress,China,2002),11.

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differencesbetweenTCMandWesternbiomedicineremainabarrierformanyto

understandTCM.24

LeonAntonioRochaexplainsthat:

OnenoticeablegapinourunderstandingofChinesemedicineremains:the

narratives,subjectivities,andexperiencesofpatients.Iamespeciallyinterestedin

howanindividualbecomesapatientofChinesemedicine:themultipleways

throughwhichapatientencountersandcomestoelectacupunctureandChinese

herbalmedicine.25

Inmypersonalexperience,mostpatientsinCanadaconsiderTCMonlyifWestern

biomedicinefailstohelpthem.TCMpatientsoftenarenotfamiliarwithTCMandreadily

acceptTCMasablackbox.Tothem,TCMisacomplementarymedicinewhenthereareno

betteroptions.Thispatientcharacteristiccanmakethemespeciallyvulnerabletounethical

practiceanddeservesourattention.InsectionIIofthisthesis,thefindingsoftheempirical

studyrevealsomepatientcharacteristicsamongtheparticipants.

RegardlessofthedifferencesbetweenTCMandWesternbiomedicine,TCMisahealthcare

intervention.AvisittoaTCMpractitionerinCanadawouldbeastandardprocessofgiving

consent,obtainingadiagnosis,formulatingatreatmentplanandthenreceivingthetherapy

accordingly.

24Fengli Lan, Culture, Philosophy, and Chinese Medicine: Viennese Lectures., Culture and Knowledge ; v. 22 (Frankfurt am Main ; New York: Peter Lang, 2012), 274.25HowardChiang,HistoricalEpistemologyandtheMakingofModernChineseMedicine(ManchesterUniversityPress,2015),238.

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TCMdiagnosis(alsoknownasBianzhenglunzhi辨証論治)isanessentialstepinaTCM

treatmentprocess.Itsprincipleistorepresentapatient’sconditioninTCMsyndrome

differentiation(alsoknownaspatterndifferentiation).Scheidwritesthat:

BianzhenglunzhiisthusrememberedtodayasthedefiningfeatureofChinese

medicine.Itscomplexhistoryhasbeenrewrittensothatforpatientsand

practitionersalike;comparisonsbetweenChinesemedicineandWesternmedicine

nownaturallyevoketheoppositionbetweenpatternanddiseasedifferentiation.26

InWesternbiomedicine,physiciansprescribetreatmentbasedonthediseasediagnosis.In

TCM,practitionersprescribetreatmentbasedontheTCMsyndromedifferentiation.Again,

Iuseaheadacheasanexampletoexplainthecontrast.InTCM,aheadachecanbe

representedbydifferentsyndromesasillustratedbelow:

26Scheid,ChineseMedicineinContemporaryChinaPluralityandSynthesis,228.

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InWesternbiomedicine,thetreatmentfordifferenttypesofheadachemaybethesame

classofprescriptiondrugs.However,inTCM,adifferentTCMsyndromerequiresa

differentTCMtreatmentplan.Forexample,aWind-Coldheadacheneedsadifferent

treatmentfromthatofaQiandBloodDeficiencyheadache.Therefore,thesamebiomedical

disease,aheadache,canrequiredifferentTCMtreatments.Twopatientswiththesame

biomedicaldiseasemayhavetwodifferentsyndromesandrequiredifferentTCM

treatments.Thesamepatientwiththesamebiomedicaldiseaseatdifferenttimesmayhave

differentsyndromesandrequiredifferentTCMtreatments.Thisfeatureof“thesame

diseasewithdifferentTCMtreatments”isauniquecharacteristicofTCM.Itisalsoan

importantfactorofwhyTCMisdifficulttostandardizeorbecomeevidence-basedmedicine.

TCMEthicalFrameworks

AlthoughTCMisamedicalsystemwhichhasitsowncompletesetoftheoriesand

treatmentmethods,thereisnouniversalTCMethicaltheoryorframeworkformoral

reasoning.AfterreviewingseveralsourcesofTCMethics,IconcludethatTCMethicsin

Canadaareinfluencedbythreedifferentsources:Chinesephilosophy,TCMmastersand

provincialregulations.

InfluencedbyvariousschoolsofChinesephilosophysuchasConfucianism,Buddhismand

Daoism,TCMethicsgravitatetowardsprinciplessuchas“Ren仁,”whichisoftentranslated

as“compassion”and“benevolence”;“Yi義,“whichisoftentranslatedas“righteousness”;

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“De德,“whichisoftentranslatedas“virtuosity”;and“Zhi智,”whichisoftentranslatedas

“wisdom”and“knowledge”.27,28Nieclaimsthat:

AsTCMevolvedinChina,itspractitioners...developedsomecoreprinciplesof

professionalethicsincludingtheconceptsofthevirtuousphysician(liangyi),

medicineastheartofhumanityorhumaneness(yinairenshu),sincerityormoral

excellence(cheng),andcompassion(ci).29

SimilartoWesternvirtueethics,Chinesephilosophyoftenemphasizesthecultivationof

moralcharacter.

LunDayiJingchengisanothersourceofTCMethics.Thebookiswrittenbyaninfluential

TCMmaster,SunSimiao(581-682).LantranslatesoneofSun’smostfamousparagraphs,

whichstatesthat“agreatdoctorshouldbeexpertinmedicalskillsandsinceretothe

patients”andthat:

whenwell-qualifieddoctorstreatpatients,theyshouldbecalmandconcentrated

withoutanydesireoravarice.Firstofall,theyshouldhavegreatsympathyforthe

patientsandthenbedeterminedtosavepeoplefromsuffering.Whenpatients

cometoaskforhelp,theyshouldnottreatthemdifferentlybywhethertheyarerich

orpoor,oldoryoung,beautifulorugly,enemyorfriend,Chineseorforeigner,

foolishorwise.Theyshouldtreatallthepatientsliketheirclosestrelatives...Being

27Chad Hansen, ‘Humanity and Nature in Chinese Thought | 中国哲学思想中的人类与自然观 | EdX’, accessed 26 October 2017, https://www.edx.org/course/humanity-nature-chinese-thought-zhong-hkux-hku03x.28Lan, Culture, Philosophy, and Chinese Medicine, section II.29Jing-Bao Nie, Medical Ethics in China: A Transcultural Interpretation, Biomedical Law and Ethics Library (London ; New York: Routledge, 2011), 181–82.

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qualifieddoctors,theyshouldregardthepatients’sufferingastheirownandhave

deepsympathyforthem.Theyshouldnottrytoavoiddangerifbeingconfronted

withit.Nomatterindaytimeornight,winterorsummer,nomattertheyarehungry

orthirsty,tiredorexhausted,theyshouldtreatorsavepatientswithheartandsoul

withoutdelayorworryingaboutpersonalgainsorlosses.Onlybysodoingcanthey

becomegreatdoctorsforpeople.30

SunSimiaopreachesselflessness,benevolenceandnon-discriminationastheHolyGrailof

TCMethics.ScheidexplainsthatSun’sideaofa“goodphysicianischaracterizedbyfour

attributes:heismorallyhonorableinhisaction(xingfang行方),hasacomprehensive

knowledge(yuanzhi圓智),andiscareful(xinxiao心小)yetalsocourageous(danda胆

大).”31Niestatesthat:

ThekeytenetofSun’sethics,asthetitleofthisimportanttextindicates,isthata

physicianmustbesimultaneously‘jing’(proficient,oratleastcompetent,inthe

studyandpracticeofmedicine)and‘cheng’(sincereinone’smoralcommitment,

honestandvirtuous).SunSimiaowasthefirsttoputforwardtheidealof‘dayi’(the

MasterPhysician)andtoarticulatetheethicalprinciplesandconductappropriateto

therole.32

Regrettably,neitherChinesephilosophynorthestudyofSun’sLunDayiJingchengare

mandatoryeducationinatypicalTCMcurriculuminCanada.ChinesephilosophyandSun’s

30Lan,Culture,Philosophy,andChineseMedicine,170.31Scheid,ChineseMedicineinContemporaryChinaPluralityandSynthesis,150.32Nie,MedicalEthicsinChina,187.

22

LunDayiJingchengarerarelytaughtinaTCMschoolinCanada.TheirinfluenceinCanada

islimited.

ThethirdsourcesofinfluenceonTCMethicsaretheStandardsofPracticeandtheCodeof

Ethicsdevelopedbytheprovincialregulations.InOntario,“theStandardsofPracticereflect

theknowledge,skillsandjudgmentR.TCMPsandR.Acsneedinordertoperformthe

servicesandproceduresthatfallwithinthescopeofpracticeoftheprofession.”33The

StandardsofPracticeprovidesareferencetotheCodeofEthicsforTCMpractitionersin

Ontarioasfollows:

UndertheCollege’sStandardsofPracticeR.TCMPsandR.Acsareexpectedtobe:

Competent-meaningtohavethenecessaryknowledge,skillsandjudgmentto

ensuresafe,effectiveandethicaloutcomesforthepatient.ThismeansthatR.TCMPs

andR.AcsmustmaintaincompetenceStandardsofPracticeintheirpractice,must

refrainfromactingifnotcompetent,andmusttakeappropriateactiontoaddress

thesituation.

Accountable-meaningtotakeresponsibilityfordecisionsandactions.Thismeans

thatR.TCMPsandR.Acsmustaccepttheconsequencesoftheirdecisionsand

actionsandactonthebasisofwhattheyintheirclinicaljudgment,believeisinthe

bestinterestsofthepatient.

Collaborative-meaningtoworkwithothermembersofthehealthcareteamto

achievethebestpossibleoutcomesforthepatient.ThismeansthatthatR.TCMPs

andR.Acsareresponsibleforcommunicatingwithothermembersofthehealth

33‘StandardsofPractice·CTCMPAOWebsite’.

23

careteam,andtakingappropriateactiontoaddressgapsanddifferencesin

judgementaboutcareprovision.34

TCMpractitionersmustadheretotheStandardsofPracticeandtheCodeofEthicssetby

theCollegeandtheBylaws.TheStandardsofPracticealsoincludeothertopicssuchas

communication,recordkeeping,advertising,andtheprohibitionofasexualrelationship

withapatient,etc.TheseguidelinesstrivetoprovideamodelforTCMpractitionersto

ensuresafe,effectiveandethicaloutcomesforpatients.35

TCMisNon-Evidence-BasedMedicine

Evidence-basedmedicineisanapproachthatintegratesindividualexpertiseandthebest

availabledatafromclinicalresearchintoclinicaldecision-making.36Inotherwords,

evidence-basedmedicineis“theconscientious,explicit,andjudicioususeofcurrentbest

evidenceinmakingdecisionsaboutthecareofindividualpatients.”37Inthecontextof

treatingapatient,evidence-basedmedicine“requiresahealthcareprovidertolocate

evidenceaboutdifferenttreatmentsforthepatient’sconditionandapplytheone

34‘StandardsofPractice·CTCMPAOWebsite’.35‘StandardsofPractice·CTCMPAOWebsite’.36DavidSackettetal.,‘EvidenceBasedMedicine:WhatItIsandWhatItIsn't.1996’,accessed1February2018,https://uottawa-primo.hosted.exlibrisgroup.com/primo_library/libweb/action/dlDisplay.do?vid=UOTTAWA&afterPDS=true&docId=TN_medline17340682&loc=adaptor,primo_central_multiple_fe.37ColleenM.Floodetal.,JustMedicareWhat’sin,What’sout,HowWeDecide,CanadianElectronicLibrary.BooksCollection(Toronto[Ont.],Toronto:UniversityofTorontoPress,2006),45,https://login.proxy.bib.uottawa.ca/login?url=http://site.ebrary.com/lib/oculottawa/Doc?id=10219133.

24

supportedbythebestevidenceabouteffectiveness”38.Thepurposeofanevidence-based

approachistooffermedicalpractitionersandpatientsmoreaccurateandup-to-date

informationabouttreatmentoptions.Ithasthepotentialbenefitofenhancingclinical

decisionmakingandoptimizationofclinicaloutcomes.39, 40, 41In1992,theEvidence-Based

MedicineWorkingGroupofAmericanMedicalAssociationclaimedthat:

...evidence-basedmedicinede-emphasizesintuition,unsystematicclinical

experience,andpatho-physiologicrationaleassufficientgroundsforclinical

decision-making,andstressestheexaminationofevidencefromclinicalresearch.

Evidence-basedmedicinerequiresnewskillsofthephysician,includingefficient

literature-searching,andtheapplicationofformalrulesofevidenceinevaluating

theclinicalliterature.42

Theimportanceofevidence-basedmedicinewasestablished.Evidence-basedmedicinehas

beenthenewparadigmformedicalpracticeandshapedtheeducationandpracticeof

biomedicinesincethe1990s.43, 44Greschnerclaimsthattheevidence-basedapproach“now

encompassesevidence-basedhealthcare,whichaspirestoextendtheprinciplesof

evidence-basedmedicinetoeverycornerofthehealthcaresystem,includingmanagement,

38Floodetal.,45.39PrasadKameshwar,‘FundamentalsofEvidenceBasedMedicine-Springer’,1,accessed24September2017,https://link-springer-com.proxy.bib.uottawa.ca/book/10.1007/978-81-322-0831-0/page/1.40Masic,Miokovic,andMuhamedagic,‘EvidenceBasedMedicine–NewApproachesandChallenges’.41Floodetal.,JustMedicareWhat’sin,What’sout,HowWeDecide,46.42GordonGuyatt,‘Evidence-BasedMedicine:ANewApproachtoTeachingthePracticeofMedicine’,JAMA268,no.17(4November1992):2420,https://doi.org/10.1001/jama.1992.03490170092032.43Guyatt,2424.44Sackettetal.,‘EvidenceBasedMedicine’,71.

25

purchasing,andprofessionalregulation.”45

Masicetal.commentthat“thekeydifferencebetweenevidence-basedmedicineand

traditionalmedicineisnotthatEBMconsiderstheevidencewhilethelatterdoesnot.Both

takeevidenceintoaccount;however,EBMdemandsbetterevidencethanhastraditionally

beenused.”46Beingnon-evidence-basedmedicineisnottheequivalenceofhavingno

evidenceorshammedicine.Therearedifferentlevelsofevidenceandwhatcountsas

evidenceiscrucial.47AccordingtotheOxfordCentre,thehighestqualityevidenceisthe

evidencegeneratedbyrandomizedclinicaltrials;inthemiddleleveloftheladderarethe

cohortorcasestudies;andatthebottomareopinions,experienceorintuition,etc.48Hence,

non-evidence-basedclinicaldecisionsmaybebasedoninsufficientevidenceorlow-quality

evidencesuchasanexpertopinion.49Incomparisontoevidence-based,non-evidence-

basedclinicaldecisionsmaynotbeoptimized.Non-evidence-basedmedicinemayimply

higheruncertaintiesandlessconsistency.Thesafetyandefficacyofnon-evidence-based

medicinemaybebiasedbytheclinicalexperienceofapractitionerorsimplyanoutcomeof

chance.50

High-qualitydataistheessenceofevidence-basedmedicine.High-qualitydatafromclinical

researchisessentialtosupportanyclaimforthesafetyorefficacyofmedicine.Among

45Floodetal.,JustMedicareWhat’sin,What’sout,HowWeDecide,45.46Masic,Miokovic,andMuhamedagic,‘EvidenceBasedMedicine–NewApproachesandChallenges’.47Floodetal.,JustMedicareWhat’sin,What’sout,HowWeDecide,44.48‘OxfordCentreforEvidence-BasedMedicine-LevelsofEvidence(March2009)’.49‘OxfordCentreforEvidence-BasedMedicine-LevelsofEvidence(March2009)’.50Kameshwar,‘FundamentalsofEvidenceBasedMedicine-Springer’,39.

26

differentclinicalresearchmethods,JulieBuringclaimsthatrandomizedclinicaltrial(RCT)

isthegoldstandardtoobtainthebestqualitydata.51Itisbecausearandomizedclinical

trialcanminimizealternativeexplanations,theroleofchance,theroleofbias,andtherole

ofconfoundinginresearchfindings.Shethinksthattheuniquenicheofrandomizedtrialsis

thattheyareoptimaltodetectstatisticallysmalltomoderatebutclinicallyworthwhile

treatmenteffects.52Thereforerandomizedclinicaltrialisthebedrockofevidence-based

medicine.Evidencefromrandomizedclinicaltrialsisregardedasthehighestlevelof

clinicalevidenceforbiomedicine.53

ThequalitiesofTCMevidenceareoftenconsideredasloworinsufficientincomparisonto

biomedicine.Asearchof“TraditionalChineseMedicine”or“acupuncture”intheCochrane

Librarydatabase(http://www.cochrane.org)wouldyieldovertwothousandreviewson

variousstudiesonTCMtherapies.Forexample,inacupunctureforfibromyalgia,the

reviewer’sconclusionisthat:

...thereislowtomoderate-levelevidencethatcomparedwithnotreatmentand

standardtherapy,acupunctureimprovespainandstiffnessinpeoplewith

fibromyalgia.Thereismoderate-levelevidencethattheeffectofacupuncturedoes

notdifferfromshamacupunctureinreducingpainorfatigue,orimprovingsleepor

51JulieBuring,‘WhyAreClinicalTrialsImportant?Lecture|WhyAreClinicalTrialsImportant?|HSPH-HMS214xCourseware|EdX’,accessed23October2017,https://courses.edx.org/courses/HarvardX/HSPH-HMS214x/2013_SOND/courseware/aa057b54817048a29ecd50c1ae205c79/7c39039dd1e747a69c49f3009927ae6d/?child=first.52LawrenceM.Friedman,CurtD.Furberg,andDavidL.DeMets,FundamentalsofClinicalTrials(NewYork,NY:SpringerNewYork,2010),https://doi.org/10.1007/978-1-4419-1586-3.53‘OxfordCentreforEvidence-BasedMedicine-LevelsofEvidence(March2009)’.

27

globalwell-being.54

Foranotherexampleinstrokerehabilitation,thereviewer’sconclusionisthat:

Fromtheavailableevidence,acupuncturemayhavebeneficialeffectsonimproving

dependency,globalneurologicaldeficiency,andsomespecificneurological

impairmentsforpeoplewithstrokeintheconvalescentstage,withnoobvious

seriousadverseevents.However,mostincludedtrialswereofinadequatequality

andsize.Thereis,therefore,inadequateevidencetodrawanyconclusionsaboutits

routineuse.Rigorouslydesigned,randomised,multi-centre,largesampletrialsof

acupunctureforstrokeareneededtofurtherassessitseffects.55

Moreevaluationspointingtoinsufficientevidenceorlow-qualityevidencecanalsobe

foundinotherexamplessuchastherapiesforinsomnia,dysmenorrhea,hyperthyroidism

andBell’spalsy,etc.Ironically,theyarecommonconditionsforwhichpatientsseekTCM

treatment.

Inareviewofevidence-basedresearchonTCM,Jin-LingTangetal.concludethatthereare

alargeandrapidlyincreasingnumberofrandomizedclinicaltrialsonTCMtherapies.

However,thequalitiesofthetrialsareusuallylowandneedimprovement.Theresearchers

identifymethodologyissuesincludingsamplesize,randomizationmethodandthecontrol

54‘AcupunctureforFibromyalgia|Cochrane’,accessed17March2018,https://doi.org/10.1002/14651858.CD007070.pub2.55‘AcupunctureforStrokeRehabilitation|Cochrane’,accessed17March2018,https://doi.org/10.1002/14651858.CD004131.pub3.

28

groupsexperiments.56InlightofthelackofscientificvigourforclinicaltrialsinTCM,Siu-

waiLeungandHaoHupublishedaTCMclinicaltrialmethodologywhich:

...emphasizedtheimportanceof(a)experimentalcontrols(placebosoractive

controls)todemonstratetheefficacy,(b)randomizationtoavoidbiasesinsampling

andgroupallocation,(c)propersamplesizecalculationtoavoidinvalidstatistical

inference,(d)blindingtoavoidperformancebiasanddetectionbias,and(e)ethical

practicestoavoidresearchmisconduct.57

Butsomescholarsthinkthatthesolutionisnotasstraightforward.YehChingLinn

commentsthatthereareinherentdifficultiesinpursuinganevidence-basedmedicine

approachforTCM.

Theindividualizedapproachandthedegreeofvariationinvolvedmake

standardizationforanEBMtypeanalysisseemdaunting.Formatoftheplacebo

eitherinacupunctureorherbalmedicinetrialposesfurtherchallengetothe

blindingprocessinRCTsforTCM.58

EarlierinthediscussionofTCMcharacteristics,IpointedoutthatTCMsyndrome

differentiationmakesTCMdifficulttostandardize.Unlikebiomedicine,TCMcannotusea

uniformsolutiontotargetaspecificdisease.Inaddition,TCMcustomizeseachtreatment

accordingtofactorssuchasthebodyconstitutionofeachindividual,seasonand

environment.Indeed,TCMisapersonalizedmedicineandattributesitseffectivenessto56Jin-LingTang,Si-YanZhan,andEdzardErnst,‘ReviewofRandomisedControlledTrialsofTraditionalChineseMedicine’,BMJ319,no.7203(17July1999):161,https://doi.org/10.1136/bmj.319.7203.160.57Siu-waiLeungandHaoHu,eds.,Evidence-BasedResearchMethodsforChineseMedicine(Singapore:SpringerSingapore,2016),2,https://doi.org/10.1007/978-981-10-2290-6.58YehChingLinn,‘Evidence-BasedMedicineforTraditionalChineseMedicine:ExploringtheEvidencefromaWesternMedicinePerspective’,ProceedingsofSingaporeHealthcare20,no.1(1March2011):14,https://doi.org/10.1177/201010581102000103.

29

adequatecustomizationforeachindividual.InTCM,clinicalprecisionmeansproactiveand

timelyvariationsfromtreatmenttotreatment,inaccordancewiththediseaseprocess.In

adjustingthetreatmentbyvaryingthechoiceordosageofherbs,acupuncturepointsor

lifestylerecommendation,forexample,theTCMpractitioneraimsatalteringthedisease

processaheadofitsprogress.

InordertoenableTCMtobecomecompatiblewithanevidence-basedapproach,there

seemstobeadisproportionateamountofresearchalreadyfocusingonqualitydataor

randomizedclinicaltrials.Randomizedclinicaltrialsareveryexpensiveundertakings.59

Feworganizationsarecapableoffundingrandomizedclinicaltrialsfortheexhaustivelists

ofTCMtherapies.Mostcutting-edgeTCMrandomizedclinicaltrialstargetthedevelopment

ofspecificbiotechnologiesorpharmaceuticalproducts.60, 61, 62, 63Theirresearchmaypave

thewayforthecommercializationofinnovativeTCMproducts,butnotnecessarilyadvance

theoveralldevelopmentofTCM.Thesuccessofafewparticularrandomizedclinicaltrials

isunlikelytoenableTCMtobecomeevidence-basedmedicineinthenearterm.

59DanielPolskyandHenryGlick,‘CostingandCostAnalysisinRandomizedControlledTrials:CaveatEmptor’,PharmacoEconomics27,no.3(2009):179–88.60AmericanAssociationfortheAdvancementofScience,‘TheArtandScienceofTraditionalMedicinePart2:MultidisciplinaryApproachesforStudyingTraditionalMedicine’,Science347,no.6219(16January2015):337–337,https://doi.org/10.1126/science.347.6219.337-c.61DennisNormile,‘TheNewFaceofTraditionalChineseMedicine’,Science299,no.5604(10January2003):188–90,https://doi.org/10.1126/science.299.5604.188.62RichardStone,‘LiftingtheVeilonTraditionalChineseMedicine’,Science319,no.5864(8February2008):709–10,https://doi.org/10.1126/science.319.5864.709.63WingLam,ScottBussom,andFulanGuan,‘TheFour-HerbChineseMedicinePHY906ReducesChemotherapy-InducedGastrointestinalToxicity|ScienceTranslationalMedicine’,accessed6November2017,http://stm.sciencemag.org/content/2/45/45ra59.

30

IamskepticalofthefeasibilityofmakingTCManevidence-basedmedicine.BridieAndrews

commentsthat,“ironically,giventhelonghistoryoftryingtomakeChinesemedicinemore

compatiblewithbiomedicine,thisEast-Westcontrasthassometimesbeenencouragedin

China.”64TheepistemologicalandontologicaldifferencesbetweenTCMandWestern

biomedicinearedifficulttoreconcile.65, 66WilliamSpenceandNaLiputforwardthat“Few

studieshaveaddressed:theapplicabilityofEvidenceBasedMedicine(EBM)toTCM,the

applicationofEBMbyTCMpractitioners,andtheirunderstandingofEBM.”67Having

qualitydataisonething.Askingpractitionerstointegratethedataintoaclinicaldecisionis

somethingelse.Butthisisoutsidethescopeofthisthesis.

Inalargercontext,OleDöringsuggeststhat“itwouldamounttoculturalsuicideifa

societywouldinvestgreatereffortsincreatingatechnicalinfrastructureaccordingtothe

stateoftheartinbiomedicinethantoencourageandnurturehumanity,includingethics.”68

IthinkthatitringstruefortheTCMcommunityaswell.TCMevidenceisimportant,soare

theethicsofthepracticeofTCM.Thisresearchthesisistofocusonthepotentialethical

issuesarisingasaresultofpracticingnon-evidence-basedmedicine.Ishallidentifythe

potentialethicalissuesusingprinciplismasastartingpoint.

64BridieAndrews,TheMakingofModernChineseMedicine,1850-1960,ContemporaryChineseStudies(VancouverBritishColumbia:UBCPress,2013),212,https://login.proxy.bib.uottawa.ca/login?url=http://books.scholarsportal.info/viewdoc.html?id=/ebooks/ebooks3/upress/2014-06-27/1/9780774824347.65Lan, Culture, Philosophy, and Chinese Medicine, 274.66Chiang,HistoricalEpistemologyandtheMakingofModernChineseMedicine,ch1.67WilliamSpenceandNaLi,‘AnExplorationofTraditionalChineseMedicinePractitioners’PerceptionsofEvidenceBasedMedicine’,ComplementaryTherapiesinClinicalPractice19,no.2(1May2013):64,https://doi.org/10.1016/j.ctcp.2013.02.003.68OleDöring,‘8.4.TeachingMedicalEthicsinChina.Cultural,SocialandEthicalIssues’,4,accessed28June2017,http://www.eubios.info/ABC4/abc4255.htm.

31

II.RespectforAutonomy

BeauchampandChildress’sprinciplismisgroundedinwhattheyrefertoas“common

moralitytheory”thateveryoneinasocietysharesasetofuniversalnorms.Normscanbe

principlesandrules,virtues,idealsorrights.BeauchampandChildressselectfour

principles:respectforautonomy,nonmaleficence,beneficence,andjusticetoconstructa

normativeframeworkforbiomedicalethics.69Theprincipleoftherespectforautonomy

containsbothanegativeandapositiveobligation.Thenegativeobligationisnon-

interferenceofpreference.Thepositiveobligationistoenableautonomousdecision-

making.70,71

Withoutsufficientorhigh-qualityevidence,itisdifficultforaTCMpractitionertooptimize

aclinicaldecisionobjectively.Theoutcomesofnon-evidence-basedmedicinecanbe

inconsistentandhavehigheruncertaintiesincomparisontoevidence-basedmedicine.The

safetyandefficacyofaTCMtreatmentcanbeanoutcomeofchance.72Ifpatientsarenot

awareoftheclinicaluncertainties,theymaynothavetherightexpectationaboutTCM

treatment.AnirrationalexpectationofTCMtreatmentiscounter-productiveintermsof

healingandpersonalfinancesforthepatient.IproposethatTCMpractitionersshould

69Beauchamp,‘TheTheory,Method,andPracticeofPrinciplism’,13.70TomL.Beauchamp,‘TheTheory,Method,andPracticeofPrinciplism’,16July2015,6,https://doi.org/10.1093/oxfordhb/9780198732365.013.31.71Beauchamp,PrinciplesofBiomedicalEthics,102.72Kameshwar,‘FundamentalsofEvidenceBasedMedicine-Springer’,39.

32

informthepatientsaboutthissituationinordertofulfillthepositiveobligationofinformed

consentbeforetreatment.

Merrillusesanempiricalstudytocollectdatafrominterviewsandquestionnaireswith

patientsandphysiciansinordertoderivehertheory.73Theapproachcan“providea

methodforshowingwhatmattersmosttopeopleaspeople,especiallyinthecontextof

medicalneeds.”74Iwasinspiredtouseanempiricalstudyintheformofasurveyinorder

toincludequalitativedatainmythesis.

SurveyMethodology

Anempiricalstudycanbequalitativeresearch,quantitativeresearchoracombinationof

thetwo.AccordingtoDeFranzo:

QualitativeResearchisprimarilyexploratoryresearch.Itisusedtogainan

understandingofunderlyingreasons,opinions,andmotivations.Itprovidesinsights

intotheproblemorhelpstodevelopideasorhypothesesforpotentialquantitative

research.QualitativeResearchisalsousedtouncovertrendsinthoughtand

opinions,anddivedeeperintotheproblem.Qualitativedatacollectionmethods

varyusingunstructuredorsemi-structuredtechniques.Somecommonmethods

includefocusgroups(groupdiscussions),individualinterviews,and

73Sarah Bishop Merrill, Defining Personhood: Toward the Ethics of Quality in Clinical Care, Value Inquiry Book Series ; v. 70 (Amsterdam ; Atlanta, Ga.: Rodopi, 1998), Forward.74Merrill,68.

33

participation/observations.75

Ontheotherhand:

QuantitativeResearchisusedtoquantifytheproblembywayofgenerating

numericaldataordatathatcanbetransformedintousablestatistics...Quantitative

Researchusesmeasurabledatatoformulatefactsanduncoverpatternsinresearch.

QuantitativedatacollectionmethodsaremuchmorestructuredthanQualitative

datacollectionmethods.76

SinceIfocusedontheopinionofTCMpatientsandexpectedthedatasampletobesmall,I

didnotaimatgeneratingpracticalstatisticsforgeneralization.Ichosetoconducta

qualitativeresearchinsteadofaquantitativeresearch.Hence,theresultsofmysurveyhas

nostatisticalpowerforgeneralization.Theconclusionsarelimitedtobeapplicabletothe

participantsofmysurvey.

Inqualitativeanalysis,therearedifferentdatatypessuchastext,images,andsound.

AccordingtoGuestetal.,text“isbyfarthemostcommonformofqualitativedataanalyzed

inthesocialandhealthsciences”77and

...textcanbeanalyzedasaproxyforexperienceinwhichweareinterestedin

individuals'perceptions,feelings,knowledge,andbehaviorasrepresentedinthe

75SusanDeFranzo,‘DifferencebetweenQualitativeandQuantitativeResearch.’,SnapSurveysBlog,16September2011,https://www.snapsurveys.com/blog/qualitative-vs-quantitative-research/.76DeFranzo.77GregGuestetal.,AppliedThematicAnalysis(LosAngeles:SagePublications,2012),8,https://login.proxy.bib.uottawa.ca/login?url=http://methods.sagepub.com/book/applied-thematic-analysis.

34

text,whichisoftengeneratedbyourinteractionwithresearchparticipants.78

Therefore,theempiricalstudyfocusedoncollectingtextanddescriptivedatafromthe

participants.Inaddition,

...givingvoiceto‘theother’isahallmarkofhumanismandhumanisticanthropology,

andthistraditionhascarriedoverintoqualitativeresearchingeneral.Thenotionof

open-endedquestionsandconversationalinquiry,sotypicalinqualitativeresearch,

isfoundedonthisprincipleasitallowsresearchparticipantstotalkaboutatopicin

theirownwords,freeoftheconstraintsimposedbythekindoffixed-response

questionstypicallyseeninquantitativestudies.Simultaneously,theresearcher

learnsfromtheparticipants'talkanddynamicallyseekstoguidetheinquiryin

responsetowhatisbeinglearned.79

Hence,Ialsousedopen-endedquestionsinthesurveyquestionnaire.

Thesmallsamplesizedidnotjustifytheuseofword-basedtechniquesorsoftwareto

performathematicanalysis.Mydataanalysisprocesswasamanualprocessofgrouping,

sortingandresortingthedataontwo-dimensionalspreadsheets.ThenIlookedforpatterns,

themes,orideasinthesmallsample.BraunandClareclaim,“athemecapturessomething

importantaboutthedatainrelationtotheresearchquestion,andrepresentssomelevelof

patternedresponseormeaningwithinthedataset.”80Guestetal.defineathemeas“aunit

ofmeaningthatisobserved(noticed)inthedatabyareaderofthetext.”81Thefindingsand

78Guestetal.,9.79Guestetal.,16.80VirginiaBraunandVictoriaClarke,‘UsingThematicAnalysisinPsychology’,QualitativeResearchinPsychology3,no.2(2006):82,https://doi.org/10.1191/1478088706qp063oa.81Guestetal.,AppliedThematicAnalysis,50.

35

interpretationaresummarizedlaterinthissection.Theyarequalitativedataandreflect

thethemesorpatternsonlyamongtheparticipantsofmysurvey.

Thequestionnairesurveyanddatacollectiontookplacefrom15October,2017,to15

January,2018.Duringthisperiod,Irandomlyinvitedanyclientswhovisitanyoneofthe

followinglocationsinOttawa:TEALWellnessat570MontrealRoad,HuntClub

PhysiotherapyClinicat2446BankStreetorInternationalAcademyofTCMat380Forest

Street.TheclientscouldbepatientsbeingtreatedwithTCM,chiropractictherapy,other

naturopathictherapies,physiotherapyormassage,etc.NotallofthemwereTCMpatients.

SomeofthemhadnevermetmenorknewofTCM.Myintentionwastocollectdatafroma

diversepoolofclients.Iwassolelyresponsiblefortherecruitmentofparticipantsatthe

surveylocations.ThequestionnairewasinEnglishonly.Eachoftheinvitationpackages

includesarecruitmentletter,animpliedconsentform,aquestionnaireandastampedself-

addressedenvelope.Iestimatedthateachquestionnairewouldtakeapproximately10

minutestocomplete.Theparticipantswereencouragedtocompletethequestionnaireat

theirconvenienceandinprivate.Therewasnoobservationofthemduringthesurvey.

SurveyResearchEthics(REBFileNumber:1360.6/17)

Theparticipationofthesurveywasanonymousandvoluntary.Theparticipantsdidnot

havetoansweranyquestionsthattheydidnotwanttoanswer.Thesurveyusedanimplied

consentmethod.Thedecisionofaparticipanttocompleteandreturnthesurveywas

interpretedasanimpliedconsenttoparticipate.Noconsentsignatureorpersonal

36

informationwascollectedonthesurvey.Therefore,afterIreceivedacompletedsurvey,the

participantcouldnotwithdrawfromthesurvey,astherewouldbenoidentificationonthe

questionnaireforretrieval.

Therewasnoobservationoftheparticipantinthissurvey.Oncetheparticipantcompleted

thesurvey,theparticipantcoulddropitoffattheofficeormaileditinthestampedself-

addressedenvelopeprovided.IfIdidnotreceivethesurveyby15January,2018,I

consideredthattheparticipantrefusedtoparticipate.Therewasnofollow-upwiththe

participantsaboutit.

Someparticipantsweremypatientsandthesurveymightcreateanapparentconflictof

interestorcoerciontoparticipateinmyresearch.Byaskingtheparticipantstocomplete

thesurveyanonymouslyandgivingthemtheoptiontoreturnthequestionnaireina

stampedself-addressedenvelope,Iresolvedthepotentialconflicts.

TheCollegeofTraditionalChineseMedicinePractitionersandAcupuncturistsofOntario

(CTCMPAO)independentlygovernsmyprofessionalconductandcompetency.Mydutyto

thepatientswasnotaffectedbytheirparticipationorrefusaltoparticipateinthisresearch.

Theresearchresultintheformofmythesiswillbetentativelyavailablebyrequestafter15

January,2019.Thereturnedquestionnairesaretobescannedintoadigitalfile.The

originalpaperrecordsaretobedestroyedafterthefinalsubmissionofthethesis.The

37

digitalfilewillbekeptinasecuredpersonalcomputerforfiveyears.Theonlypersonwho

haveaccesstotheresearchdatawillbeme.

Duringthecourseofthesurvey,theprocesswasincompliancewiththeapprovedresearch

ethicsproposal.Onedeficiencywasinthedesignofthequestionnaireforasmallsample

group.Askingdetaileddemographicinformationfromasmallsamplegroupcouldexposea

participant’sidentitytome.Theanonymityofsomeparticipantscouldbecompromised

becauseofexcessivedetailsinthedemographicssection.Theremedywastoremindthe

participantsthattheydidnothavetoansweranyquestionthattheydidnotwantto

answer.

SurveyParticipants

Theparticipantswererandomlyselectedamongtheclientswhovisitedanyoneofthe

threelocationsinOttawa(TEALWellnessat570MontrealRoad,HuntClubPhysiotherapy

Clinicat2446BankStreet.orInternationalAcademyofTCMat380ForestStreet.)The

clientscouldbepatientsbeingtreatedwithTCM,chiropractictherapy,othernaturopathic

therapy,physiotherapyormassages.Myintentionwastocollectdatafromamorediverse

poolofpatients.Iwassolelyresponsiblefortherecruitmentofparticipantsatthesurvey

locations.Table1belowsummarizesthedemographicdata.

38

Table1:DemographicData(n=17)

Characteristics Number (n) Percentage% Sex:

Male 2 11.76%Female 15 88.24%Other 0 0.00%Noanswer 0 0.00%

Age: Under20 1 5.88%20-40 7 41.18%41-60 4 23.53%Over60 5 29.41%Noanswer 0 0.00%

Education: None 0 0.00%Highschoolorequivalent 1 5.88%Postsecondaryorequivalent 16 94.12%Noanswer 0 0.00%

Ethnicity: White 11 64.71%Latino 0 0.00%Black 0 0.00%IndigenousPeople 2 11.76%Chinese 0 0.00%Arab/WestAsian 3 17.65%East/SoutheastAsian 0 0.00%Indian/SouthAsian 0 0.00%Noanswer 1 5.88%

FrequencyofusingTCM: Never 3 17.65%Lessthanonceperyear 2 11.76%Atleastonceperyear 11 64.71%Noanswer 1 5.88%

Thesurveyexcludedanyparticipantsunder17yearsofage(Ontario),parents,andparents

orauthorizedthirdpartiesofadultparticipantswhowouldbelegallyincompetenttogive

39

consent.Thesurveyquestionnairebeganbycollectingthedemographicdataofthe

participantsabouttheirsex,agerange,educationlevel,ethnicityandhowoftentheyused

TCM.Eachanswerwasvoluntary.Therewasnocompulsionfortheparticipantstoreveal

informationthatmightidentifythemtome.

Asof15January,2018,Iinvited35peopleintotaltoparticipateinthesurvey.31ofthe

invitationstookplaceatthelocationofTEALWellnessat570MontrealRoad.Fourofthe

invitationstookplaceatthelocationofHuntClubPhysiotherapyClinic.Noneofthe

invitationstookplaceattheInternationalAcademy.Ofthe35invitations,17participants

providedimpliedconsentandreturnedtheirquestionnaireswithanswers.

Themajorityoftheparticipantsarewhitefemaleswithagefrom20to60.Almostallof

themhavepost-secondaryeducation.Manyofthemaremypatientsandhavesome

experienceofTCM.Thereweretwolessonslearnedintheinvitationprocess.First,the

invitationstookplacemostlyatonelocationinsteadofbeingevenlydistributedamong

threelocations.Itwasduetotheconcentrationofmyworkscheduleduringthesurvey

periodatTEALWellness.Second,sometimesIforgotordidnothavethetimetoinvite

everyonethatImetonthesameday.Itwasduetomypre-occupationwiththepatients

duringtreatments.Inordertoincreasethenumberanddiversityofinvitationsamongthe

threesites,Ishouldhavevisitedthethreesitesoutsidemyclinicscheduleandmade

invitationsoutsidemyclinichours.

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SurveyFindingsandInterpretation

Thesmallsamplesizedidnotjustifytheuseofword-basedtechniquesorsoftwareto

performathematicanalysis.Theanalysiswasamanualprocessofanalyzingthedataon

spreadsheets,lookingforapattern,themes,orideasinthesmallsample.Thefindingsand

interpretationweresummarizedbelow.

Table2:AwarenessofTCMasnon-EBMandFrequencyofUsingTCM(n=17)

Participant No.

Aware TCM non

EBM Use TCM Frequency

1 yes Atleastonceperyear2 yes Atleastonceperyear3 yes Atleastonceperyear4 yes Atleastonceperyear5 yes Atleastonceperyear6 yes Atleastonceperyear14 yes Atleastonceperyear15 yes Atleastonceperyear16 yes Atleastonceperyear7 yes Lessthanonceperyear17 yes Never8 no Atleastonceperyear9 no Atleastonceperyear10 no Lessthanonceperyear11 no Never13 no Never12 no Noanswer

Table2aboveillustratestheawarenessoftheparticipantaboutTCMbeingnon-evidence-

based.Theparticipantnumberinthefirstcolumnwasrandomlyassignedtoeachreturned

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questionnaireforthepurposeofdataentry.ColumntwoistheanswertoQuestion1ofthe

questionnaire.ThequestionnaireexplainsthatTCMisnotconsideredasevidence-based

medicinebyWesternmedicalstandardsandaTCMtreatmentmaybeeffectiveonlyby

chance.Itasksiftheparticipantisawareofthesituation.Amajorityoftheparticipants

(n=11,64.7%)answeredthattheywereawareofTCMbeingnon-evidence-basedmedicine.

ColumnthreeindicateshowoftentheparticipantusesTCM.Theanswerscanbe“Never”,

“Lessthanonceperyear”or“Atleastonceperyear”inthedemographicssection.

Bysortingandgroupingthedataaccordingtotheiranswersaboutthefrequencyoftheir

usingTCM,Iproducedthreegroups(A,B,C)ofdatasamplesforfurtheranalysis.The

frequencyofusingTCMimpliestheirexperienceofTCM:

• GroupAconsistsofparticipantswhocheckedeither‘Lessthanonceperyear’or‘At

leastmorethanonceperyear’inthedemographicssection.Therefore,GroupA

representstheparticipantswhohaverelativelymoreexperienceofusingTCM.

• GroupBconsistsofparticipantswhocheckedeither‘Never’or‘Lessthanonceper

year’inthedemographicssection.Therefore,GroupBrepresentstheparticipants

whohaverelativelylessexperienceofusingTCM.

• GroupCconsistsofparticipantswhogavenoanswer.Theseparticipantsareneither

inGroupAnorinGroupB.

GroupAandBhaveoverlappingparticipants(i.e.participantswhouseTCMlessthanonce

peryear;n=2)TheoverlappingofsampledatacreatesalargersamplesizeforbothGroup

AandGroupBinthemeanalysis.Thistechniquealsoallowsmetointerprettheresults

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overamorecontinuousdegreeofTCMexperienceamongtheparticipants(i.e.relatively

moreorlessexperienceinusingTCM.)

Table3:AnswersfromGroupA(participantswhohavemoreexperienceofusingTCMn=13)Aware TCM

non EBM Verbatim Answer to Question 1a or 1b

yes IprefertotryTCMbeforemedication.Ithasworkedinthepastforme.

yes

Asanindigenouswoman(orFirstNations)we'vebeenusingtraditionalmedicine'scedar,tobacco,sage,sweetgrass,sweatlodges,fastformanyyears.Chinesemedicineissimilarinhistoryasto"notobjectivelyverified"bycurrentgovernmentstandards,FDAapprovaletc."Ibelieveinit".

yes BecauseI'vehadsuccesswithitinthepastfortreatmentofmychronicpaincondition.

yes Itworksforme,it'squick&effectivebetterformethanwesternbased.Idon'tlikepillsormedicationtotreatailmentsorpain.

yes VeryeffectiveforcervicaldystoniaincombinationwithBotoxthatIreceiveatCivicHospital.

yes Forreliefoftherelevantpain/discomfort;andforthegeneralfeelingofwellnessIhaveafteranytreatment.

yesIbelieveinanaturalwayofhealingdiseases.IamnotagainstWesternmedicine,butthroughmyexperience,TCMhelpsmealotofregainingmystrengthandgeneralhealth.

yes

AsIamamicabletoholisticapproachestomedicine,IfindthatTCMhelpsmyphysicalailmentstremendously.However,oneofthebiggestissuesismainstreammedicinenotacceptingorbelievinginTCMandinsurancecompaniesnotprovidinganycoverageforsuchtreatments.ThesetwoareasarethemostfrustratingwhichdecreasesmychancestoseekTCMtreatments.Ideally,evenifnotevidence-based,mainstreamdoctorsandinsurersshouldgivetheirpatients/clientsthefreedomtochooseortoseektreatmentsthathelpthemfeelbetterorhealfaster.

yes TCMmaynotfollow"Westernmedicalstandards"butisatriedandtruetreatment-trial&error-itworks.

yes Iwaswillingtotrybecauseacupuncturehasbeenshowntohelppainandfertility,evenifwedon'tknowwhy.

noBecausemymotherdiditinthepast.SoIdecidetotrybecauseIwastakingtoomuchpainkiller.Now,Ireduced3/4ofmypainkiller.Myhandsarenolongerswellinginthemorning,IhavemoreenergyandIfeelbetterinmybody.

no HavinghadtreatmentsbeforeIfoundtheyweregenerallybeneficialtomywell-being.

no Itdoesn'taffectmydecisiontouseTCM

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Table3aboveorganizestheanswerstoQuestion1,1aand1bforGroupA.Table4below

organizestheanswersofQuestion1,1aand1bforGroupB.Thefirstcolumnofbothtables

containstheansweroftheparticipantstowhethertheyareawarethatTCMisnot

evidence-basedinQuestion1.Thesecondcolumnofbothtablescontainstheverbatim

answeroftheparticipantsofhowdoesbeingnon-evidence-basedaffecttheirdecisionto

useTCMineitherquestion1aand1b.Imademinimalcorrectionofsomespellingerrors

andgrammarinthedata.However,noneoftheircontentwasalteredduringtheprocess.

ByanalyzingTable3,twothemesemergefromGroupA.First,themajority(n=10or

76.9%)ofparticipantsinGroupAwereawareofTCMbeingnon-evidence-basedmedicine.

Second,indecidingtouseTCM,themajorityofthem(n=12,92.3%)explainedthedecision

wasbasedonpositivepastexperienceorexpectationoffuturebenefitssuchas“willingto

try,”“Ibelieveinit,”“Itworked”or“Ifeelbetter”.Therewaslittlementionofconcerns

aboutuncertaintiesorrisksassociatedwithnon-evidence-basedmedicine.

Table4:AnswersfromGroupB(participantswhohavelessexperienceofusingTCMn=5)

Aware TCM non EBM Verbatim Answer to Question 1a or 1b

yes Iwaswillingtotrybecauseacupuncturehasbeenshowntohelppainandfertility,evenifwedon'tknowwhy.

yes Ibelieveinalternativemedicine.no Itdoesn'taffectmydecisiontouseTCM

no

BecauseifitworksonlybychancethenIwouldn'twanttoriskitandpaymoneyifitwon'twork.IfIamgoingtogettreatedIwouldlikethepercentageofittoworkmuchhigherthenifitdidn'twork.Not50%yesand50%no.

no Morehesitantaboutthebenefits.

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AsshowninTable4above,themajority(n=3,60%)oftheparticipantsinGroupBwerenot

awareofTCMbeingnon-evidence-basedmedicine.SomeparticipantsinGroupBindicated

concernsovertherisksassociatedwiththeuseofTCM.ThesamplesizeofGroupBissmall.

Nevertheless,thedatashowsthecontrastbetweenGroupAandGroupB.

GroupChasonlyoneparticipantwhodidnotprovideananswertothefrequencyofusing

TCM.TheparticipantwasnotawareofTCMbeingnon-evidence-basedmedicine.The

verbatimansweris“Itriedphysiotherapy,physiotherapywithtriggerpointdryneedling;

verylittlebenefitandverypainfulneedling.Problempersists.”GroupCwasnotincludedin

anythemeanalysisbecausethegrouphasonlyoneparticipant.

Question2ofthesurveyprovidesabriefexplanationoffourethicalprinciples(autonomy,

beneficence,justiceandnonmaleficence).Thenitfollowstoasktheparticipanttorankthe

priority(1,2,3or4)foreachethicalprincipleinTCM.Therankof“1”indicatesthehighest

priorityandtherankof“4”indicatesthelowestpriorityamongthefourprinciples.The

participantscanchoosemorethanoneprinciplestohavethesamerank.

TherewasaprintingerrorinQuestion2intwelveofthequestionnaires.Insteadof

“Autonomy”,itwasprintedas“Consent”.Therefore,allresponsesrelatedtotherankingof

“Autonomy”or“Consent”weresubsequentlynotusedmyanalysis.

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Table5:AwarenessofTCMasnon-EBMandtheCorrespondingRankingsof“Beneficence”,“Justice”and“Nonmaleficence”(n=17)

Aware TCM non EBM

Priority of Beneficence

Priority of Justice

Priority of Nonmaleficence

no 1 1 1no 1 1 1no 1 1 1no 1 1 3no 1 4 1no 3 4 3yes 1 1 1yes 1 1 1yes 1 1 1yes 1 1 1yes 1 1 1yes 1 1 2yes 1 3 2yes 1 4 3yes 3 3 4yes 4 3 3yes 4 4 4

Sortingthedatafirstbytheparticipants’awarenessofTCMbeingnon-EBM,secondbythe

rankingof“Beneficence”andthirdbytherankingof“Justice”yieldedTable5above.The

topsixrowsofthedatacamefromparticipantswhowerenotawareofTCMbeingnon-

EBM.Thebottomelevenrowsofthedatacamefromparticipantswhowereawarethat

TCMbeingnon-EBM.

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OnethemeemergesfromTable5.AmongtheparticipantswhowereawareofTCMbeing

non-EBM,8outof11(i.e.72.7%)ranked“1”forBeneficence,6outof11(i.e.54.54%)

ranked“1”forJusticeand5outof11(i.e.45.45%)ranked“1”forNonmaleficence.The

participantswhowereawareofTCMbeingnon-EBMconsideredtheprincipleof

beneficencehavingahigherpriorityovernonmaleficenceinTCM.Thisthemeisin

agreementwiththethemederivedfromTable3forGroupA.ThemoreexperiencedTCM

patientswereoftenawareofTCMbeingnon-EBM.Theyfocusedonthepotentialbenefitsof

TCMintheirverbatimresponseswithlittlementionoftherisksassociatedwithTCM.

ByrearrangingthecolumnsofTable5andsortingthedataaccordinglytofirstbythe

rankingof“Beneficence”,secondbytherankingof“Justice”andthirdbytherankingof

“Nonmaleficence”yieldedTable6below.OnethemeemergesfromTable6below.The

numberofparticipantswhoranked“1”forBeneficenceis13outof17(i.e.76.47%),ranked

“1”forJusticeis10outof17(i.e.58.82%)andranked“1”forNonmaleficenceis9outof17

(i.e.52.94%).Themajorityofallparticipantsalsoconsideredtheprincipleofbeneficence

havingahigherpriorityoverjusticeornonmaleficenceinTCM.Thethemeagreeswiththe

previousthemesfoundinTable3andTable5.

Inaddition,regardlessofthedataoftherankingof“Autonomy”or“Consent”(asinthe

misprintedquestionnaires),Table6showsthatlessthanhalf(n=<8,47%)ofthe

participantsconsideralltheethicalprinciplesareequallyimportanttotheminTCM.

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Table6:Rankingsof“Beneficence”,“Justice”and“Nonmaleficence”ofAllParticipants(n=17)

Priority of Beneficence

Priority of

Justice

Priority of Nonmaleficence

Aware TCM non

EBM 1 1 1 yes1 1 1 yes1 1 1 yes1 1 1 yes1 1 1 yes1 1 1 no1 1 1 no1 1 1 no1 1 2 yes1 1 3 no1 3 2 yes1 4 1 no1 4 3 yes3 3 4 yes3 4 3 no4 3 3 yes4 4 4 yes

ConclusionsoftheSurvey

Theparticipants’awarenessofTCMbeingnon-evidence-basedmedicineshowed

correlationwiththeirexperienceofusingTCM.ParticipantswhohadmoreTCMexperience

weremoreoftenawareofTCMbeingnon-evidence-basedmedicine.Participantswhohad

lessexperiencewithTCMwerelessawareofTCMbeingnon-evidence-basedmedicine.

ForparticipantswhohadmoreTCMexperience,theinformationofTCMasnon-evidence-

basedmedicineshowedlittleimpactontheirdecisiontouseTCM.Theirverbatim

responsesindicatedtheirpastandindividualexperienceofTCMaffectedtheirdecisionto

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useTCM.Theygaveahigherprioritytotheprincipleofbeneficenceovernonmaleficencein

TCM.TheyfocusedonthepotentialbenefitsofTCMinsteadoftheuncertainties.ForTCM

practitionerstofulfillthepositiveobligationoftherespectforautonomy,itisimportant

thattheyconscientiouslyremindTCMpatientstoconsidertheuncertaintiesassociated

withTCMoverbenefits.Forexample,patientsshouldnotdelayhavingabiomedical

diagnosisbecauseofusingTCMorreplaceeffectivebiomedicinewithTCMtherapywithout

high-qualityevidence.

ForparticipantswhohadnoorrelativelylessexperiencewithTCM,thesurveyshowedthat

theirverbatimresponsesexpressedsomeconsiderationsofrisksoverthebenefitsofusing

TCM.ThedisclosureofTCMbeingnon-evidence-basedmedicinemighthaveanimpacton

theirdecisiontouseTCM.Therefore,thedisclosurewouldbematerialinformationtohelp

themmakethedecisionofusingTCM.Basedonthepositiveobligationundertheprinciple

ofrespectforautonomy,TCMpractitionersshouldinformnewpatientsthatTCMisnon-

evidence-basedmedicine.Itcanbeincorporatedintothemandatoryprocessofobtaining

informedconsentbeforetreatment.ItwillhelpnewTCMpatientstomakeautonomous

decisionsandsettherightexpectationofTCMaccordingly.

Therewerelessonslearned.Onelessonwasthatexcessivedetailsinthedemographics

sectionforasmallsamplesizecouldcompromisetheanonymityoftheparticipants.

Anotherlessonpertainedtotheschedulingoftheinvitationprocessinordertoincrease

thesizeanddiversityofthedata.

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Althoughthissmall-scalequestionnairesurveyusesqualitativeanalysisandhasno

statisticalpowerforgeneralization,itisstillaworthyexperience.Ithintsthatalarger-scale

studyonTCMpatientscanbeusefulandfeasibleinthefuture.Withsufficient

participationsfrommultipleTCMpractitionersindifferentlocations,alargersurveymay

bedevelopedtostudythespecificneedsandexpectationsofTCMpatientsinalarger

population.ThefindingsmayhelpTCMpractitionerstoidentifythebestpracticesandmost

productivewaystocomplementtheconventionalmedicineinthatpopulation.InsectionII

andIV,IalsodiscusstheneedforTCMresearchinotherareas.

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III.BeneficenceandNonmaleficence

BeauchampandChildressassertthat“moralityrequiresnotonlythatwetreatpersons

autonomouslyandrefrainfromharmingthem,butalsothatwecontributetotheir

welfare.”82Theprincipleofnonmaleficencemeansnottocauseharmsuchaspain,

sufferingordistresstoothers.83Theprincipleofbeneficenceobligatesustoactforthe

benefitofothersandthescopecanincludepreventingharm,removingharm,and

promotinggood.84BeauchampandChildressputforwardthatthefourprinciplesin

principlismshouldhavenohierarchyandtheyaremorallyweightedequallyinthe

framework.85Whentheseprinciplesareinconflictwitheachother,thesituationmustbe

assessedinspecificcontextswithoutassuminganypriorityovertheothers.Sometimes

non-maleficenceismorestringentthanbeneficencebutsometimesthereverseisalso

true.86

Forexample,insertinganacupunctureneedleintoaperson’sbodymaycauseharmsuchas

painorbruisebutitsimultaneouslycanrelieveorpreventtheperson’sheadache.

Beneficencetakespriorityovernon-maleficenceinthiscase.NowconsideraTCM

practitionerwhodoesnothavetherequiredTCMcompetenciesandhewantstopractice

82Beauchamp,PrinciplesofBiomedicalEthics,202.83Beauchamp,‘TheTheory,Method,andPracticeofPrinciplism’,8.84Beauchamp,9.85Beauchamp,2.86Beauchamp,PrinciplesofBiomedicalEthics,151.

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acupunctureonpatients.Althoughhisintentionistohelpothers,hisactioncanpotentially

causeharm.Nonmaleficenceoverridesbeneficenceinthiscase.

Non-evidence-basedmedicinecansometimesbeanexpertopinionwithoutanexplicit

criticalappraisal.87, 88CompoundedbythelackofstandardizationinTCM,itisoften

difficultforthepatientaswellasthepractitionertodistinguishshamsfromeffectiveTCM

treatment.AnexamplecanbefoundintheearlierdayswhenTCMwasnotregulatedin

Canada.Inthosedays,thetypicalemploymentmodelforTCMpractitionerwasworkingfor

aherbalstore.TheusualroleofTCMpractitionerwastodiagnosepatientsandprovidefree

herbalprescriptions.However,purchasingtheherbalprescriptionsisnotfree.Toincrease

profitability,herbalstoreownerscouldmandatetheTCMpractitionertoprescribehigher-

profit-marginoverlower-profit-marginherbs.Boththepractitionerandthepatientwould

havelittlebasistocompareefficacyorsafetyinsuchcase.

Someexamplescanalsobespottedintoday’smarketplace.InthenameofTCM,thereisno

shortageofinnovativetreatmentssuchas“TCMdetox”,“TCMweightloss”,“cosmeticTCM

acupuncture”,etc.Althoughatreatmentmayusethetechniquessuchasacupunctureor

Chineseherbs,itmaynothaveanybasisofTCMtheoryorTCMdiagnosis.Somenew

treatmentsmayalsolackevidenceofsafetyoreffectiveness.TCMpractitionershavethe

obligationstodistinguishshamsfromeffectiveTCMbeforepromotingthem.Notdoingthe

duediligenceorpracticingunproventherapiesonpatientsisunethicaleventhoughTCMis87AlastairMcColletal.,‘GeneralPractitioners’PerceptionsoftheRoutetoEvidenceBasedMedicine:AQuestionnaireSurvey’,BMJ316,no.7128(31January1998):361,https://doi.org/10.1136/bmj.316.7128.361.88‘OxfordCentreforEvidence-BasedMedicine-LevelsofEvidence(March2009)’.

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consideredasnon-evidence-basedmedicine.TheguidelinesandmethodsforTCM

practitionerstoperformduediligenceonTCMtherapiesisaworthyresearchsubject.Butit

isoutsidethescopeofthisthesis.

TCMpatientsoftenarenotfamiliarwithTCMandrelyonthepractitionertoexplainsafety

andefficacy.71%ofCanadianshaveusednaturalhealthproductslikevitaminsand

minerals,herbalproductsandhomeopathicmedicines.89IfyouaskHealthCanada“How

canIusenaturalhealthproductssafely?”theirregularresponsewillbe“Talktoahealth

careprofessionallikeadoctor,pharmacistornaturopathbeforechoosingaproduct.”90

SimilarlyinTCM,ensuringthesafetyandefficacyofTCMisoftentheresponsibilityofTCM

practitioners.

InsectionII,theresultsoftheempiricalstudyshowedthatthemajorityofparticipants

considerbeneficenceahigherpriorityovernonmaleficenceinTCM.MoreexperiencedTCM

patientswereoftenawareofTCMbeingnon-evidence-basedmedicine.However,theywere

inclinedtofocusonthepotentialbenefitsinsteadoftherisks.Thispatientcharacteristic

makesthemparticularlyvulnerabletoTCMshamsandunethicalpractices.ATCM

practitionerwhorespectstheprinciplesofnonmaleficenceandbeneficencewouldlikely

havetheprofessionalproficiency,performingduediligenceonTCMtherapies,tooffer

89HealthCanadaandHealthCanada,‘AboutNaturalHealthProducts’,organizationaldescriptions,aem,26November2010,https://www.canada.ca/en/health-canada/services/drugs-health-products/natural-non-prescription/regulation/about-products.html.90‘AboutNaturalHealthProducts’,aem,26November2010,https://www.canada.ca/en/health-canada/services/drugs-health-products/natural-non-prescription/regulation/about-products.html.

53

honesthealthadviceinthebestinterestsofthepatients.ATCMpractitionerwho

disregardstheprinciplesofnonmaleficenceorbeneficence,ontheotherhand,islesslikely

tomeettherequiredstandardsofpracticeordoduediligenceonTCMtreatments.Worse,

anunethicalpractitionermayprioritizeprofitsoverpatientinterestsandintentionally

promoteTCMshamstothepublic.

WhatcanbethemosteffectivewaytoensureTCMpractitionersadheretoethical

principlesandstandardsofpractice?Iexploresolutionsinthecultivationofmoral

characterandtheTCMpractitioner-patientrelationshipmodelasfollows.

MoralCharacter

Manymedicalprofessionalstandardsandtheircodesofethicspromotecertainmoral

values.Forexample,theethicalguideoftheCanadianMedicalAssociationforCanadian

physiciansstatesthat:

ThisCode...Itisbasedonthefundamentalprinciplesandvaluesofmedicalethics,

especiallycompassion,beneficence,non-maleficence,respectforpersons,justice

andaccountability.TheCode,togetherwithCMApoliciesonspecifictopics,

constitutesacompilationofguidelinesthatcanprovideacommonethical

frameworkforCanadianphysicians.91

AnotherexampleisintheethicalguideoftheCanadianNurseAssociation.Itscodeofethics

listssevenprimaryvaluesas:91CMA,‘CodeofEthics’,https://www.cma.ca/En/Pages/code-of-ethics.aspx,accessed25March2017,https://www.cma.ca/En/Pages/code-of-ethics.aspx.

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1.Providingsafe,compassionate,competentandethicalcare2.Promotinghealth

andwell-being3.Promotingandrespectinginformeddecision-making4.Preserving

dignity5.Maintainingprivacyandconfidentiality6.Promotingjustice7.Being

accountable.92

Healthcareprofessionalsareoftenrequiredtocultivatemoralcharacter.Virtuessuchas

“compassion,discernment,trustworthiness,integrity,andconscientiousness...are

importantinpartforthedevelopmentandexpressionofcaring.”93

Chinesephilosophyalsoemphasizesthecultivationofvirtues.Chinesemoralvaluessuchas

compassion,benevolenceandwisdomarehonourable,praise-worthyvirtuesinany

Chinesesocieties,particularlyinthemedicalprofession.

Aristotle,thefoundingfatherofvirtueethicsintheWest,definesvirtueasastateof

“involvingrationalchoice,consistinginameanrelativetousanddeterminedbyreason–

thereason,thatisbyreferencetowhichthepracticallywisepersonwoulddetermineit.”94

Virtueethicssuggeststhatapersonshouldliveinaccordancewithreasonandexercise

prudenceinconductinghimself.Adheringtovirtueethics,aTCMpractitionerwould

proactivelyapplythenecessaryStandardsofPracticeandCodeofEthicsinorderto

providesafe,ethicalandeffectivetreatment.JustinOakleyassertsthat:

92‘NursingEthics’,accessed1March2017,https://www.cna-aiic.ca/en/on-the-issues/best-nursing/nursing-ethics.93Beauchamp,PrinciplesofBiomedicalEthics,37.94Aristotle,Aristotle:NicomacheanEthics,trans.RogerCrisp,2edition(NewYork:CambridgeUniversityPress,2014),31.

55

...acommonwayofexpressingadmirationorcondemnationofanother’sbehaviour

isbysaying‘Whatsortofpersonwoulddoathinglikethat?’...Virtueethicsisan

approachthatpicksuponthesecommonwaysofjudgingactions.Itholdsthat

actionscannotbeproperlyjudgedasrightorwrongwithoutreferenceto

considerationsofcharacter.95

Virtueethicsattendstotheimportanceofmoralcharacter,notjustfollowinga

deontologicalcode.Oakleyaddsthat:

...othermainstreamtheoriesevaluateallactsintermsof‘right,’‘wrong,’‘obligatory,’

or‘permissible,’andindoingsoleaveuswithanimpoverishedmoralvocabulary.A

virtueethicsapproach,bycontrast,employssuchevaluativetermsas‘courageous,’

‘callous,’‘honest,’and‘just’–aswellasthemorefamiliar‘right’and‘wrong’–and

therebyprovidesamuchricherandmorefine-grainedrangeofevaluative

possibilities.96

AccordingtoAristotle,moralcharacterisinparttheresultofhabit:

Virtueisoftwokinds:thatoftheintellectandthatofcharacter.Intellectualvirtue

owesitsoriginanddevelopmentmainlytoteaching,forwhichreasonitsattainment

requiresexperienceandtime;virtueofcharacterisaresultofhabituation(ethos),

forwhichreasonithasacquireditsnamethroughasmallvariationon‘ethos’.97

95JustinOakley,‘AVirtueEthicsApproach’,inACompaniontoBioethics,ed.HelgaKuhseandPeterSinger(Wiley-Blackwell,2009),91,https://doi.org/10.1002/9781444307818.ch10.96Oakley,92.97Aristotle,Aristotle,23.

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Todeveloptherelevantmoralcharacter,weneedtopracticeprudenceintherelevant

activities.Forexample,ifwewanttodeveloptherightmoralcharacterforcaringpeople,

weneedtodevelopthatmoralcharacterbypracticingcaringotherpeople.Innursing

education,RegnerBirkelundholdsaviewthat:

...socialcarecannotbetaughtbymeansoftheories,butcanbelearntonlythrough

practice.Themaster–apprenticeprincipleofancientGreeceisstressedin

connectionwiththisasbeingaviablealternativetothetheoreticalmodelof

education.98

BirkelundquotesMatinsenasalsosaying“themoralandpracticalaspectofnursingcannot

belearnedfromtheoriesaboutcareandethics,butfromhands-onexperience.”99

Scholarsalsopointouttheimportanceofrolemodelinginethicseducation.HigginsandJo

claimthat“ForAristotle,webecomemoralbylivingamongethicalexemplarsandby

learningtodesirewhatisgood.”100DerekSellmansuggests“thebestteachersof

professionalphronesismayturnouttobethosepractitioners(includingpractitionersof

teaching)whoexemplifytheprofessionalphronimos(orprofessionallywise

practitioner).”101Insometrainingexperience,Irecallobservingthevaluesofclinical

98RegnerBirkelund,‘EthicsandEducation’,1,accessed13October2017,https://journals-scholarsportal-info.proxy.bib.uottawa.ca/details/09697330/v07i0006/473_eae.xml.99Birkelund,475.100ChristopherHigginsandKatherineJo,‘EthicsandEducation-Education-OxfordBibliographies-Obo’,accessed13October2017,http://www.oxfordbibliographies.com.proxy.bib.uottawa.ca/view/document/obo-9780199756810/obo-9780199756810-0142.xml;jsessionid=3B8BDC8023E0878C565A114823E6794B.101DerekSellman,‘PracticalWisdominHealthandSocialCare:TeachingforProfessionalPhronesis’,accessed14October2017,https://journals-scholarsportal-info.proxy.bib.uottawa.ca/details/14736853/v08i0002/84_pwihasctfpp.xml&sub=all.

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sensitivity,humanecommitmentandTCMscholarshipfromtheinteractionsoftheTCM

teacherswithpatients.TheTCMpractitioner-patientrelationshipcanmakeadifferencein

thequalityofTCMcare.Bymanagingthepracticalmattersinaclinicalenvironment,the

teacherscouldconvincemethevaluesofethicswithoutpreachingethics.

Practitioner-PatientRelationshipModel

EmanuelandEmanuelanalyzefourmodelsofphysician-patientrelationship.Theyarethe

paternalistic,informative,interpretiveanddeliberativemodels.Inthepaternalisticmodel,

“thephysicianactsasthepatient’sguardian,articulatingandimplementingwhatisbestfor

thepatient.”102Intheinformativemodel,thephysicianactsasatechnologisttoprovideall

theavailablefactsforthepatienttomaketheinformeddecision.103Intheinterpretive

model,“thephysicianisacounsellor....supplyingrelevantinformation,helpingtoelucidate

valuesandsuggestingwhatmedicalinterventionsrealizethesevalues.”104Inthe

deliberativemodel,“thephysicianactsasateacherorafriend,engagingthepatientin

dialogueonwhatcourseofactionwouldbebest.”105Althoughthereareprosandconsof

eachmodel,EmanuelandEmanuelsupportthedeliberativemodelastheidealphysician-

patientrelationshipmainlybecausethemodelembodiestheidealofautonomy,promotes

evaluativediscussionsofhealthissuesandavoidsimposingthephysician’svalues.106In

102EmanuelandEmanuel,‘FourModelsofthePhysician-PatientRelationship’,2221.103EmanuelandEmanuel,2221.104EmanuelandEmanuel,2222.105EmanuelandEmanuel,2222.106EmanuelandEmanuel,2223–26.

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addition,thedeliberativemodelofphysician-patientrelationshipalsorequiresthepractice

ofcaring:

Theessenceofdoctoringisafabricofknowledge,understanding,teaching,and

action,inwhichthecaringphysicianintegratesthepatient'smedicalconditionand

health-relatedvalues,makesarecommendationontheappropriatecourseofaction,

andtriestopersuadethepatientoftheworthinessofthisapproachandthevaluesit

realizes.Thephysicianwithacaringattitudeistheidealembodiedinthe

deliberativemodel...107

Intuitively,thefourmodelsarealsoapplicabletoTCMpractitioner-patientrelationship.

IuseobesityasanexampletoexplorehowaTCMpractitionermayimplementthefour

models.Imaginethatapatientisalreadydiagnosedwithobesitybyhisphysician.Hewants

toseektreatmentinTCM.Inapaternalisticmodel,aTCMpractitionermaypledge“Ishall

domybesttohelpyou”andthenproceedwiththeappropriateTCMdiagnosesand

treatments.Inaninformativemodel,aTCMpractitionermayaddinformationsuchasa

varietyofoptionsinacupuncture,herbaltreatments,dietsandexercise,etc.Theobjective

istoallowthepatienttocompareeachtreatmentoptionandmakeaninformedselection

forhimself.Inaninterpretativemodel,aTCMpractitionermayalsoimposethat“obesity

addstotherisksofotherdiseasessuchasdiabetes,heartdiseaseandcancer.Beingobese

isunhealthyandyoushouldloseweight.”Usuallyifonecaresaboutaperson,onewould

askquestionsabouttheperson.Inadeliberativemodel,aTCMpractitionerwouldlikely

askthepatientquestionssuchas“howdoyoumanage?”or“whatissuitable?”or“whyisit

107EmanuelandEmanuel,2226.

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difficult?”tounderstandtheneeds,expectationsandvaluesofthepatient.Itmayturnout

thatthepatientdoesnotconsiderthehigherriskofotherdiseasesunhealthy.Theobjective

ofthepatientmaybetoalleviatehisknee-painduetobeingoverweight.Inthiscase,being

pain-freemeansbeinghealthyforthepatient.Withsuchanunderstanding,thepractitioner

maydiligentlyincludethemeasurementofpainintheevaluationofthetreatment’s

progress.Thepractitionermayalsohelpthepatientexploreothertherapiessuchas

physiotherapyormassagetocopewithpain.Atalaterstage,thepractitionercan

encouragethepatienttoconsiderothervaluesofhealth,suchaslowerdiseaseriskfactors,

throughmoreevaluativediscussions.

TCMisaholisticmedicine.ItalsoembodiesChineseculturalvaluessuchasideals,rituals

andbeliefs.SinceTCMpractitionersusuallyincludelifestyleadvicetopatients,suchasdiet

orexercise,aspartofthecompletetreatment.ItiseasyforTCMpractitionerstoimpose

Chineseculturalvaluessubconsciouslyonpatientsduringtheconsultation.The

deliberativemodelofpractitioner-patientrelationshipisthebestmodelforapractitioner

tosafeguardtherespectforpatientautonomy.

ThedeliberativemodelisidealforTCMforanotherreason.Asmentionedearlier,TCM

patientsareoftennotfamiliarwithTCMandrelyontheirpractitionerstoexplainsafety

andefficacyissues.TheempiricalstudyinsectionIIalsofoundthatthemajorityof

participantsfocusonthepotentialbenefitsinsteadoftherisks.Thischaracteristicpointsto

patientvulnerabilitytounethicalpractice.Usingtheaboveexampleofobesity,itappears

thatnoneofthefourpractitioner-patientrelationshipmodelscanpreventanunethical

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practitionerfrompromotingshamweight-lossproducts.However,inimplementingthe

deliberativemodel,thepatientmayhaveabetterchancetoremindhimselfabouthis

treatmentobjectiveandevaluatetheprogressinaccordancewithhisexpectation.

Inordertoimplementthedeliberativemodelofphysician-patientrelationship,Emanuel

andEmanuelassertthat:

...physicianscurrentlylackthetrainingandcapacitytoarticulatethevalues

underlyingtheirrecommendationsandpersuadepatientsthatthesevaluesare

worthy...Therefore,ifthedeliberativemodelseemsmostappropriate,thenweneed

toimplementchangesinmedicalcareandeducationtoencourageamorecaring

approach.Wemuststressunderstandingratherthanmereprovisionsoffactual

informationinkeepingwiththelegalstandardsofinformedconsentandmedical

malpractice;wemusteducatephysiciansnotjusttospendmoretimeinphysician

patientcommunicationbuttoelucidateandarticulatethevaluesunderlyingtheir

medicalcaredecisions,includingroutineones.108

IfTCMistopromotethedeliberativemodelforthepractitioner-patientrelationship,TCM

practitionersmayalsoneedspecialtraining.

Boththecultivationofmoralcharacterandimplementationofidealpractitioner-patient

relationshipdirectustoexamineTCMtrainingandeducation.TCMstudentsaregoingtobe

ourfutureTCMpractitioners.ToensureahighstandardofTCMethicsandcompetencyfor

thelongterm,itmakessensetoinvestinTCMeducationandtraining.

108EmanuelandEmanuel,2226.

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Teacher-ApprenticeLearningModel

InCanada,TCMethicseducationoftenmeansreadingtheStandardsofPracticeandthe

CodeofEthicsdevelopedbytheprovincialregulations.Forexample,theCollegeof

TraditionalChineseMedicinePractitionersandAcupuncturistsofOntariorequiresallTCM

practitionerstostudythejurisprudencehandbookandpassthejurisprudenceexamination

beforeregistrationforTCMpractice.Thejurisprudencehandbookfocusesontopicssuchas

patientcommunications,safepractice,recordkeepingandadvertising,since,“thepurpose

ofthesepublicationsistoremindpractitionersaboutthefactorsthatarerequiredto

practicesafely,ethicallyandeffectively.”109

However,jurisprudencedoesnotentailthedevelopmentofmoralvaluesinpractitioners.

Unschuldcommentsthat:

Themereaffirmationofacodeofethicswillnotsufficetoestablishpublictrust.For

onething‘formulatedethics’utilizetherelevantvaluesofthecomprehensive

paradigmsfoundinthepublic,butatthesametimecontainveryconcrete

regulationsofbehaviourfortheindividualphysician.Theseregulationsof

behaviour,asforexampletheforbiddingofadvertising,hardlyseemtorelateto

ethics.110

Döringsuggeststhatmedicalethicseducationshouldbe:109‘JurisprudenceCourse·CTCMPAOWebsite’,handbookp.8.110Paul U. Unschuld, Medical Ethics in Imperial China: A Study in Historical Anthropology, Comparative Studies of Health Systems and Medical Care ; (Berkeley: University of California Press, 1979), 14.

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...morefundamentally,asawaytoimprovethecapacitiesofmedicalprofessionals

to‘dotherightthing’,accordingtothetraditionalconceptofmedicineasan‘artof

humaneness’...Inthissense,medicinehasanintrinsicmoraldrive,makingitdistinct

fromventuresthatprovidemeretechnicalbiomedicalservicesorproceduralskills

inhandlinglegalorpoliticalcontroversies.111

TCMeducationsysteminCanadacanbenefitfrommoretoolsoralternativesolutionsto

supplementethicseducationinthecurrentcurriculums.TheTCMteacher-apprentice

learningmodelencompassestheelementsofpracticingcaring,habituationandmentorship.

Thelearningmodelcanbeeffectiveforcultivatingmoralcharacterandpromotingthe

deliberativemodelofpractitioner-patientrelationshipamongTCMstudents.Itisworthyof

investigation.

Theteacher-apprenticelearningmodelisnotnewinChinesemedicine.Unschuldexplains

that:

...perhapsthemostcommonroutetobecomingaphysicianofChinesemedicine

untiltheendofthenineteenthcenturywasbywayofapprenticeship.The

modernizationofChinesemedicineattemptedfromwithintheChinesemedicine

circlesduringthelateQingandRepublicanerasledtotheopeningofschoolsand

collegesinmanycitiesandprovincesthatmodeledthemselvesonuniversitiesand

technicalcollegesandsoughttoemulateWesternmedicaltraining.112

TodayinChina,theteacher-apprenticeeducationisalreadyrevivedintheTCMeducation

programandintegratedintoinstitutionaleducation.Xueetal.writethat:111OleDöring,‘8.4.TeachingMedicalEthicsinChina.Cultural,SocialandEthicalIssues’,1.112Unschuld, Medical Ethics in Imperial China, 168–69.

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...theBeijingUniversityofChineseMedicine...in2007...adopteda‘TCMeducation

reformexperimentalprogram.’Studentswereadmittedtothisprogrambyan

independentstudentrecruitmentprocessthatselectedapplicantsfromfamiliesof

TCMpractitionersinsteadofthroughacollegeentranceexamination.Onceenrolled,

studentswereassignedtodifferentsupervisors.Thisprogramisacombinationof

institutionaleducation,master-apprenticeeducation,andfather-soneducation

models.113

ImplementingtheTCMteacher-apprenticelearningmodelisatestedsolutioninChina.Itis

feasibletointegrateitintotheexistinginstitutionalsysteminCanada.Besidesenhancing

TCMethicseducation,thelearningmodelmayalsoenhancethestandardsofTCMpractice

intwootherways.Firstbyeffectivestudentselectionandsecond,byincreasingtheir

clinicalexperience.Inaddition,itcanfacilitatecontinuingeducationamongTCM

practitioners.

StudentSelection

SelectingtherightstudentstolearnTCMistoselecttherightpeopletopracticeTCMinthe

future.InhisexperienceofteachingbiomedicalethicsinChinain2002,Döringquotesfrom

theYixueyuzhexuejournal(‘MedicineandPhilosophy’)that:

...onlyasmallsegmentofmedicalstudentsexpressaninterestinethicalissues.Only

about19%ofthestudents,whohadbeeninterviewedareactuallyinterestedin

113PeiXueetal.,‘ComparisonofChineseMedicineHigherEducationProgramsinChinaandFiveWesternCountries’,JournalofTraditionalChineseMedicalSciences2,no.4(1October2015):228,https://doi.org/10.1016/j.jtcms.2016.01.010.

64

helpingpeople.Atstakeisnotonlyanethicallywellreflected,reasonablemedical

practice,butalso,howtogainmoresupportfromphysiciansandsociety?19%is

lessthanoneinfiveofmedicalstudents.114

Ifapersondoesnotbelieveinhelpingpeopleorrespectingsocietynormsthenwhydowe

wantthispersontoperformhealthcare?Itisinefficienttodevelopvirtuessuchas

compassion,benevolenceorjusticeinthisperson.Worse,thispersonmayexertanegative

influenceonotherstudents.Döringsuggeststhatamongmedicalstudents:

...agenuineinterestin‘doingtherightthing’servesasaconstantreminderofeach

one'smoralinspiration.Itstimulatesandencouragesstudentstodevelopthe

relevantcapacitiestobecome‘good’indoingtheirjobright,formingamoral

character,whichcorrespondswiththemoralintuitionsandtheprofessionalcalling

thatmakeadoctorchoosehisprofessioninthefirstplace.115

TCMeducationinstitutionsshouldselectstudentswhodemonstrateadesiretohelpand

careaboutotherstopracticeTCM.

InCanada,almostallTCMeducationandtrainingareoperatedasprivatecareertraining

institutions.Forexample,mostTCMcollegesinBCareDesignatedPrivateTraining

Institutions116and“Humber’sTraditionalChineseMedicinePractitioner(TCMP)advanced

diplomaprogramisthefirstandonlypubliclyfundedprogramofitskindofferedata

114OleDöring,‘8.4.TeachingMedicalEthicsinChina.Cultural,SocialandEthicalIssues’,3.115OleDöring,1.116‘PrivateTrainingInstitutionDirectory|PrivateTrainingInstitutionsBranch’,accessed6February2018,https://www.privatetraininginstitutions.gov.bc.ca/students/pti-directory.

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postsecondaryinstitutioninCanada”117.CurrentlyinOntario,startingupaTCMcareer

trainingschooldoesnotevenrequireapprovalunderthePrivateCareerCollegesAct.118

Foraprivatecareertraininginstitution,studentsareprimarilythecustomers.Likeany

othertypeofbusiness,itisreasonabletoexpectaprivatecareertraininginstitutionto

welcomeasmanycustomersaspossible.Beingselectiveintheadmissionofstudent

applicantscanbecounter-productivetoprofitability.Itisnotrealistictoexpectaprivate

TCMeducationinstitutiontobeselectiveofTCMstudents.

Currently,thecostisprobablythebiggestbarrierofentrytobecomingaTCMstudent.The

costofattendinganhouroftraininginaTCMschoolisabout$15perhour.Forexample,in

BritishColumbia,theminimalhoursoftraininginaTCMAcupunctureProgramis1,900

hours.Thus,thetotalcostofcompletingaTCMAcupuncturistprograminBritishColumbia

isapproximately$15x1,900hours=$28,500.TheacademicprerequisitestoenterTCM

schoolsarestipulatedbytheprovincialregulatorsandvaryfromprovincetoprovince.For

example,BritishColumbiaTCMstudentapplicantsrequiretwoyearsofcollegeor

universityeducationandOntarioTCMstudentapplicantsrequireGrade12education.In

comparisontootherhealthprofessionssuchasdental,nursingorphysiotherapydegree

programsataCanadianuniversity,itisrelativelyeasytobeadmittedintoaTCMeducation

program.

117‘TraditionalChineseMedicinePractitioner’,accessed6February2018,http://healthsciences.humber.ca/programs/traditional-chinese-medicine-practitioner.html.118GovernmentofOntario,‘PrivateCareerColleges(PCC)’,accessed6February2018,http://www.tcu.gov.on.ca/pepg/audiences/pcc/private.html.

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Incontrasttoaprivateinstitutionalsetting,ateacher-apprenticetrainingmodelismore

effectiveinstudentselection.ThemainreasonistheinfluenceofConfucianism.According

toConfucianteaching,apersoncannotexistinisolationbutalwaysinasocialcontext.The

natureofapersonisdefinedbyhissocialrelationshipsandresponsibilities.119Volker

Scheidpointsoutthat“discipleshipinChinesemedicine(asinotherChineseartsand

crafts)isfoundedonthepatternofthefamilyandcanbedocumentedasfarbackasthe

secondcenturyB.C.”120and“socialrelationsbetweenmasteranddisciplethenasnoware

modeledonthefilialrelationshipbetweenfatherandson,oneofthefivecardinal

relationships(wulun五倫)ofConfucianideology.”121

ToaTCMteacher,anapprenticeislikeachild.Givenachoicebetweenbeingvirtuousor

wicked,anyparentwouldprefertheirchildrentobevirtuous.Givenachoicebetween

havingtheintellectorlackofintellect,anyparentwouldprefertheirchildrentohavethe

intellect.Therefore,inateacher-apprenticemodel,ateacherhasanincentivetoselecta

TCMstudentwithagoodintellectandmoralcharacter.

ThehourlywageofpresentingaTCMlessoninaprivatecareertraininginstitutionin

Canadaisabout$35perhour.Incontrast,aTCMpractitionercanearnanaverageof$40to

$120pertreatmentinCanada.ItisdifficulttoattractthebestTCMpractitionerstoleave

theirpracticeandteachataTCMschool.Inaninstitution,astudentcannotchoosehisown

119Hansen, ‘Humanity and Nature in Chinese Thought | 中国哲学思想中的人类与自然观 | EdX’.120Scheid,ChineseMedicineinContemporaryChinaPluralityandSynthesis,169.121Scheid,169.

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teachers.Thestudentshavetolearnfromthedesignatedteachersregardlessofthequality

oftheteachers.However,inateacher-apprenticemodel,astudentcanchoosehisown

teacher.AstudentshouldbefreetoapplyandlearnfromthebestqualifyingTCM

practitioner.ItfollowsthatbetterTCMteachersdevelopbetterTCMstudents.

IntensiveClinicalPractice

Thereisanadditionalbenefitinimplementingtheteacher-apprenticeapproach.Itcan

directlyenhancetheclinicalcompetencylevelofTCMgraduatesinCanada.Inthecontext

ofWesternbiomedicine,J.Boudreauwritesthat“medicalpracticerequiresablendof

intellectualpursuits:theoretical,practical,productiveandperformative...Notwithstanding

themultifacetednatureofmedicine,thephysicianisprimarilyengagedinapractical

activity.”122Manyscholarssupportlearningthroughpracticeasabetterapproachtothe

educationofstudentsinhealthcare.Boudreauclaimsthat:

...medicineaimstopromotehealthandtorelievesuffering,anditsultimateaimis

thewell-beingofthepatient.Athreattowell-beingisperceivedwhenpersons

sufferimpairmentsoffunctionthatinterferewiththeattainmentoftheirpurposes

andgoalsinlife.Thus,well-being,aslivedandunderstoodbythepatient,isthe

touchstoneofmedicineandmustalsoserveasthefulcrumuponwhichamedical

educationprogramisconstructed.”123

122J.Boudreau,‘TheHumanitiesinMedicalEducation:WaysofKnowing,DoingandBeing’,JournalofMedicalHumanities36,no.4(1December2015):329.123Boudreau,329.

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Similarly,TCMclinicaltrainingandpracticalexperiencearecrucialinpreparingaTCM

studenttobecomeacompetentpractitionerandpracticeindependentlyinthefuture.

Chinahashadstate-runTCMpostsecondaryeducationsince1956andtheirnationalTCM

curriculumhasbeenevolving.124Noticeably,theirTCMclinicaltraininghasbeenmuch

moreintensivethanthatinCanada.TodayinChina,majorTCMuniversitiesuseanintegral

trainingmodelwhichcombinesaBachelorandMasterdegreefortheirTCMstudents.For

example,BeijingUniversityofChineseMedicineoffersan“integrated‘fiveplusthree’

programwhichcomprises5yearsofundergraduatetrainingwithpreclinicalcoursesand3

yearsofinternshiptraining.”125BasedonChina’sNationalTCMcoursecurriculumfor

1997126,thetotalclinicaltraininginthefirstfiveyearsofundergraduatetrainingis

approximately687hours.Inaddition,thesubsequentinternshiptrainingispracticallyfull-

timepracticeinTCMhospitals.Iestimatethenumberofpatientcase-studiesduringthe

TCMinternshiptraining,excludingthe687clinicalhoursinthefirstfiveyearsof

undergraduatetraining.Basedonatwo-yearinternship,50workweeksandsixworkdays

perweekschedule,aTCMinternspendsabout600days(i.e.2*50*6=600)practicingTCM

inaTCMhospital.InthreedifferentTCMuniversityhospitalsinChina,IfoundthataTCM

internusuallypracticedanaveragenumberof40patientcasesinaday.Thatmeansthe

TCMinternwouldpracticeabout24,000(i.e.600*40=24,000)patientcasesinthetwo

yearsofinternship.

124Taylor, Chinese Medicine in Early Communist China, 1945-63, Ch.3-4.125Xueetal.,‘ComparisonofChineseMedicineHigherEducationProgramsinChinaandFiveWesternCountries’,228.126Taylor,ChineseMedicineinEarlyCommunistChina,1945-63,163.

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UsingtheTCMregulationsinBritishColumbiaforcomparison,theminimumtotalclinical

trainingrequirementforaTCMacupunctureprogramgraduateis500hours.127Abouthalf

ofthetotalclinicaltrainingisobservationandtheotherhalfissupervisedpracticeon

patients.Afull-timeTCMacupuncturestudentusuallyspendseighthoursperweekin

clinicaltraining.Thattranslateintoabout62.5weeks(i.e.500/8=62.5)ofclinicalpractice.

Someschoolclinicsarebusierthantheothers.Basedonmypersonalexperience,Iestimate

aTCMacupuncturestudentstudiesanaverageofsevenpatientcasesinaschoolclinicper

week.ThatmeansaTCMacupuncturestudentstudiesanaveragenumberof437.5(i.e.

62.5*7=437.5)patientcasesinhis500clinicaltraininghours.

Incomparison,theclinicaltrainingforTCMstudentsinChinaismoreintensivetothatof

TCMstudentsinCanada.AlthoughTCMstudentsinCanadalearnfromthesameTCM

textbooksandpasssimilarTCMexaminations,thegraduatesmaylackclinicalexperience,

intuitionandjudgmentincomparisontothegraduatesinChina.TheCanadianpublic

deservesthesamequalityofTCMgraduates.Theeducationofateacher-apprentice

learningmodeloftentakesplaceinaclinicalenvironmentsimilartoaninternship.Notonly

isitaneffectiveapproachtoteachTCMethicsandselectTCMstudents,itdirectlyincreases

thequantityandqualityofclinicalexperienceforfutureTCMpractitionersinCanada.

SunSimiao’sideaofa“goodphysicianischaracterizedbyfourattributes:heismorally

honorableinhisaction(xingfang行方),hasacomprehensiveknowledge(yuanzhi圓智),

127‘EducationProgramReview|CTCMA-CollegeofTraditionalChineseMedicinePractitionersandAcupuncturists’.

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andiscareful(xinxiao心小)yetalsocourageous(danda胆大).”128Itisdifficultforanyone

tobecomeanexcellentTCMpractitionerafterjust500hoursofclinicalobservationand

practice.Hence,continuingeducationisimportantforanyTCMpractitioner.Allregistered

TCMpractitionersarerequiredtoobtainacertaincontinuingeducationinCanada.

Currently,mostcontinuingeducationisconductedintheformatofinstitutionalcoursesor

seminars.

InsomeTCMuniversity-hospitalsinChina,TCMpractitionersregularlyconferwiththeir

TCMpeersaswellasexternalbiomedicalprofessionalsinresolvingpatientcases.Indeed,

inCanada,IhavemetotherhealthcareprofessionalswhoareopenandinterestedinTCM.

Somehealthcareprofessionalssuchasmedicalphysicians,nursesandphysiotherapistare

opentoworkingwithTCMpractitionersinresolvinghealthissues.Consideringpeersand

otherhealthcareprofessionalsasteachersinstudyingpatientcases,asinateacher-

apprenticelearningmodel,canbeaproductivewayofTCMcontinuingeducation.Forsome

TCMpractitionersinsmallercitiesorruralcommunities,theirlocationsofpracticecanbe

farfromanyTCMschoolsoreducationinstitution.Thisalternativemodelofcontinuing

educationcanreducetheburdenofsuspendingtheirpracticesorlong-distancetravelto

attendcontinuingeducationcourses.Theteacher-apprenticelearningmodelcanfacilitate

continuingeducationintheirlocalcommunities.

128Scheid,ChineseMedicineinContemporaryChinaPluralityandSynthesis,150.

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IV.Justice

TCMtherapyisnotpubliclyfundedinsuredhealthserviceinCanada.Itispaidasanout-of-

pocketexpensebyaTCMpatient.Somepatientsmayhaveprivatehealthinsurance

throughtheiremploymenttocoversomeacupuncture.Ingeneral,wealthierpatientshave

moreaccesstoTCMtreatmentthanthosewhohavefewermeans.TheaccesstoTCMcareis

notequalandisbasedonthepatient’sabilitytopay.Isthisjust?

Justiceisoneofthefourprinciplesofprinciplism.BeauchampandChildressexplainthat:

...thetermfairness,desert(whatisdeserved),andentitlementhavebeenusedby

philosophersasabasisonwhichtoexplicatethetermjustice.Theseaccounts

interpretjusticeasfair,equitable,andappropriatetreatmentinlightofwhatisdue

orowedtopersons.129

Subsequently,thetermdistributivejusticereferstofair,equitable,andappropriate

distributionofbenefitsandresponsibilitiesasdeterminedbyoursocietalnorms.130

Intheprevioussectionspertainingtotheprinciplesofrespectforautonomy,beneficence

andnonmaleficence,Ihavepointedoutthepotentialethicalissuesofpracticingnon-

evidence-basedmedicineandalsosuggestedsolutionstoaddressthem.Inthissection,my

discussionfocusesonthefair,equitable,andappropriateaccesstoTCMcareinCanada.

Danielsisoneofthefirstscholarstoarguefortherighttohealthcareandresearchthe

129Beauchamp,PrinciplesofBiomedicalEthics,250.130Beauchamp,250.

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distributivejusticeinhealthcare.Heexplainsthatthenotionofaccessiscomplicatedand

itsconsiderationcannotbedetermineduntilweclarifyacompositeoffactorssuchas

“whattheaccessisto,”“by“whom”andmoralprinciples.131Inordertoputthissectionin

thepropercontext,IsituatetheentirediscussioninthecontextofCanada’spubliclyfunded

healthcaresystem(medicare)andtheCanadaHealthAct.

MedicareandInsuredHealthService

TheCanadaHealthActisCanada'sfederallegislationformedicare132and“fromthetop,

CanadaHealthActdrivesdecision-makingaboutwhatisinandwhatisoutofCanadian

Medicare.”133Itsetsouttheprimaryobjectiveofourhealthcarepolicyas"toprotect,

promoteandrestorethephysicalandmentalwell-beingofresidentsofCanadaandto

facilitatereasonableaccesstohealthserviceswithoutfinancialorotherbarriers."134

Canada’smedicareisasingle-payeruniversalhealthcaresystem.Thesystemisfinancedby

ourmultiplelevelsofgovernmentsandcoversthecostsofessentialhealthcareforall

residents.Itisasingle-payerinsurancesysteminwhichourgovernmentscollecttaxesand

paysforallhealthcarecosts.“Historically,thefederalgovernmentencouragedthe

adoptionofpubliclyadministeredsingle-payerinsurancesystemsintheprovincesthrough

131NormanDaniels,JustHealthCare,c1985,Ch.4,59-85.132HealthCanadaandHealthCanada,‘CanadaHealthAct’,navigationpage,aem,26July2004,https://www.canada.ca/en/health-canada/services/health-care-system/canada-health-care-system-medicare/canada-health-act.html.133Floodetal.,JustMedicareWhat’sin,What’sout,HowWeDecide,17.134CanadaandCanada,‘CanadaHealthAct’.

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theuseofthefederalspendingpower.”135Althoughtheprovincesareresponsibleforthe

directdeliveryofmostmedicalservices,thefederalgovernmentusesitsspendingpowerto

influenceCanadianhealthcarethroughfinancialcontributionknownasCanadaHealth

Transfer.

Thereareprosandconsofasingle-payersystem:

Proponentsofasingle-payersystemarguethatbecausetherearefewerentities

involvedinthehealthcaresystem,thesystemcanavoidanenormousamountof

administrativewaste.Instead,allhealthcareprovidersinasingle-payersystem

wouldbilloneentityfortheirservices.Withinasingle-payersystem,allcitizens

wouldreceivehigh-quality,comprehensivemedicalcarePLUSthefreedomto

chooseproviderstoagreaterextentthanmostnetwork-basedhealthplansallow.

Paperworkwouldalsobedramaticallyreduced.136

Ontheotherhand,“asinglepayersystemalonedoesnotaddress‘fee-for-service’

reimbursementforproviders,whichmayencourageoveruseanddoesnotrecognize

qualityandvalue.”137Thebottomlineisthatthefundingforanyhealthcaresystemisnot

unlimited.Asingle-payersystemdoesnotautomaticallyresolvethelimitationofresources.

ThroughCanadaHealthTransfer,thefederalgovernmentprovides“long-termpredictable

135Romanow,BuildingonValuestheFutureofHealthCareinCanada,46.136‘Single-PayerSystemDefinition’,healthinsurance.org,23September2017,https://www.healthinsurance.org/glossary/single-payer-system/.137DarshakSanghaviandSarahBleiberg,‘CanCanadian-StyleHealthcareWorkinAmerica?VermontThinksSo.’,Brookings(blog),30November2001,https://www.brookings.edu/blog/up-front/2014/01/22/can-canadian-style-healthcare-work-in-america-vermont-thinks-so/.

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fundingforhealthcare,andsupportstheprinciplesoftheCanadaHealthActwhichare:

universality;comprehensiveness;portability;accessibility;and,publicadministration.”138

Forexample,OntariohospitalsareprimarilyfundedbytheMinistryofHealthandLong

TermCarethroughprovincialpaymentsallocatedfromCanadaHealthTransfer.139The

fundingallocationisprimarilybasedonhistoricalfundingpatternswithmarginalyear-

over-yearincreasesordecreases.140TheCanadaHealthTransferforOntarioisabout

$14.36billionin2017-2018andabout$14.96billionin2018-2019withanincreaseinline

withathree-yearmovingaverageofnominalGrossDomesticProduct.141

TheCanadaHealthActestablishescriteriaandconditionsrelatedtothehealthcare

servicesthattheprovincesandterritoriesmustfulfillinordertoreceivethefederal

transferpayments.142TheaimoftheCanadaHealthActis“toensurethatalleligible

residentsofCanadahavereasonableaccesstoinsuredhealthservicesonaprepaidbasis,

withoutdirectchargesatthepointofserviceforsuchservices.”143Asaresearcherwhohas

workedextensivelyonthecomparisonofvariouspubliclyfundedhealthcareprograms,

FloodsummarizesthefoundingprinciplesofCanada’smedicareas:

138DepartmentofFinanceGovernmentofCanada,‘CanadaHealthTransfer’,federaltransfers,1January2000,https://www.fin.gc.ca/fedprov/cht-eng.asp.139DonDrummond,‘ChartingaPathtoSustainableHealthCareinOntario:10ProposalstoRestrainCostGrowthwithoutCompromisingQualityofCare-ScholarsPortalBooks’,27,accessed4December2017,http://books2.scholarsportal.info.proxy.bib.uottawa.ca/viewdoc.html?id=/ebooks/ebooks1/gibson_chrc/2010-08-20/1/10397929#tabview=tab1.140Drummond,28.141DepartmentofFinanceGovernmentofCanada,‘FederalSupporttoProvincesandTerritories’,federaltransfers,15December2014,https://www.fin.gc.ca/fedprov/mtp-eng.asp#Ontario.142CanadaandCanada,‘CanadaHealthAct’.143CanadaandCanada.

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1)thataccessto‘medicallynecessary’hospitalandphysicianservicesarebasedon

medicalneed,notabilitytopay;and2)thatservicescoveredbymedicareare

fundedalmostexclusivelythroughgeneraltaxationrevenues.144

Ouruniversalhealthcarecoveragebeganwithhospitalsinthe1950sandphysician

servicesinthe1960s.145Today,itcoversawiderangeofmedicallynecessaryservicessuch

as:

o hospitalservicesthataremedicallynecessaryforthepurposeofmaintaining

health,preventingdiseaseordiagnosingortreatinganinjury,illnessor

disability,including accommodationandmeals,physicianandnursing

services,drugsandallmedicalandsurgicalequipmentandsupplies;

o anymedicallyrequiredservicesrenderedbymedicalpractitioners;and

o anymedicallyordentallyrequiredsurgical-dentalprocedureswhichcan

onlybeproperlycarriedoutinahospital.146

TheCanadaHealthActalsostipulatesthat:

...extendedhealthcareservicesincludeintermediatecareinnursinghomes,adult

residentialcareservice,homecareserviceandambulatoryhealthcare

services...whichdonothavetobepubliclyadministered,universal,comprehensive,

accessibleorportable.Inaddition,provincialhealthcareinsuranceplansmaycover

otherhealthservices,suchasoptometricservices,dentalcare,assistivedevicesand

144ColleenM.Floodetal.,‘DefiningtheMedicare“Basket”’,1,accessed4February2018,http://www.deslibris.ca.proxy.bib.uottawa.ca/ID/250981.145Romanow,BuildingonValuestheFutureofHealthCareinCanada,73.146OdetteMadore,‘TheCanadaHealthAct:OverviewandOptions’,accessed30November2017,https://lop.parl.ca/content/lop/researchpublications/944-e.htm#4insuredtxt.

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prescriptiondrugs,whicharenotsubjecttotheAct,andforwhichprovincesmay

demandpaymentfrompatients.Therangeofsuchadditionalhealthbenefitsthat

areprovidedunderprovincialgovernmentplans,therateofcoverage,andthe

categoriesofbeneficiariesvarygreatlyfromoneprovincetoanother.147

Currently,mostextendedhealthcareservicessuchasdentalcare,physiotherapy,TCMor

othercomplementarymedicineareout-of-pocketexpensesforthepatients.

Althoughthenotionofmedicallynecessaryplaysanimportantroleindecidingwhat

shouldbeinsuredhealthservice,theconceptofmedicalnecessityisnotdefinedinthe

CanadaHealthAct:

...theActdoesnotsetoutaprocessfordeterminingthosemedicallynecessary

healthservices.Therefore,eachprovince(incollaborationwiththeprovincial

medicalassociation)isresponsiblefordeterminingwhatspecificservicesaretobe

insuredunderthepublichealth-careinsuranceplan.Becauseprovincesdonotusea

systematicmethodfordeterminingtheprovisionofcomprehensivehealth-care

services,publiccoverageforcertainhealthservicesacrossthecountryisuneven.148

Romanowagreesthat“thedefinitionofwhatisconsideredmedicallynecessaryand

coveredundertheActneedstobeupdatedtoreflecttherealitiesofourcontemporary

healthcaresystem.”149Thenarrowfocusmighthaveledtotheneglectofotherhealth

147Madore.148‘TheCanadaHealthAct’,accessed31January2018,https://lop.parl.ca/Content/LOP/ResearchPublications/tips/tip74-e.htm.149Romanow,BuildingonValuestheFutureofHealthCareinCanada,47.

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producingmeasures.150Thedefinitionofmedicallynecessaryisunclearandmaynotmeet

thecurrentneedsofCanadians.

Inexplainingthedecision-makingframeworkinfundingmedicare,Floodclaimsthatthere

are“significantlydifferentapproachestofundingdependingonwhatsectorwearedealing

with,whetherphysicianservices,hospitalservices,newtechnologies,pharmaceuticals,or

homecare”151ForexampleinOntario,determiningwhatphysicianservicesareinsured

healthservicesinvolvesatleastthefollowingbodies:

(1)ThePhysicianServicesCommittee,whichisajointcommitteecomprising

officialsfromtheMinistryofHealthandLongTermCare(theMinistry)andthe

OntarioMedicalAssociation(OMA);(2)MedicalDirectorswhoaresalaried

physicianswithintheMinistryandmaydetermineclaimsforpublicfunding;(3)the

HealthServicesAppealandReviewBoard;and(4)thecourts.152

Floodpointsoutthat“decision-makingregardingwhichphysicianservicesaretobefunded

isdrivenbytheprocessoffeenegotiationsbetweentheMinistryandtheOMA...Bydefault

theseservicesaredeemedmedicallynecessary.”153Thereisalackoftransparencyabout

theguidingprinciplesinthedecision-makingprocess.154“Furthermore,thereisenormous

resistancetochangingtherangeandtypesofservicesthatwepubliclyfund,primarilyby

individualswithvestedinterestsinmaintainingpublicfundingforcertainprocedures.”155

150‘Cost–BenefitAnalysisandHealthCareEvaluations,SecondEdition’,28November2014,16–17,https://www-elgaronline-com.proxy.bib.uottawa.ca/view/9781781004586.xml.151Floodetal.,JustMedicareWhat’sin,What’sout,HowWeDecide,17.152Floodetal.,18.153Floodetal.,18.154Floodetal.,19.155Floodetal.,30.

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Asaresult,thereislimitedflexibilityforthesystemtoreplaceoraddnewservices.156

Floodconcludesthatcurrently,thedecisionsaboutthecontentsofmedicarebasketis

largelyshapedbythefollowing:

1. accidentsofhistoryandlong-heldaccommodationsbetweengovernments

andthemedicalprofession;and

2. inflexibleandinadequateregulationsandlaw,andturfprotectionand

lobbyingbydifferentstakeholdersandinterestgroups.157

Thereisminimalpublicparticipationorproceduralfairnessinthedecision-makingprocess

andFloodrecommendsthat:

...iftheprocessofdeterminingwhatisinandwhatisoutofMedicarecouldbe

unbuckledfromdeterminationsofwhichphysicianservicestofund,thenitmay

becomepossibletoestablishamorerigorousandprinciplesprocess,infusedwith

publicparticipation,thatwouldallowrelativelyhighbenefitservicesand

technologiestobefundedinplaceoflowerbenefitservicesandtechnologies.158

Basedonthecurrentdecision-makingprocessoffundinginsuredhealthservice,our

currentmedicarebasketmaynotbejust.Thereisroomforchange.

ShouldTCMbeanInsuredHealthService?

Thepurposeofthisthesisistoreflectonpotentialethicalissues.Resolvingthepotential

ethicalissuespertainingtotheprinciplesofautonomy,beneficenceandnonmaleficence

156Floodetal.,30.157Floodetal.,‘DefiningtheMedicare“Basket”’,6.158Floodetal.,JustMedicareWhat’sin,What’sout,HowWeDecide,20.

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shouldprecederesolvingdistributivejusticeofTCM.Whatisthepointofhavingequal

accesstoTCMifthesafetyorefficacyofTCMisuncertain?Coincidentally,thesurveyin

sectionIIshowedthatthemajorityofparticipantsalsoprioritizedtheprinciplesof

beneficenceoverjustice.

TCMhasitshistoryofstruggleinCanada.159,160Before2012,fewerthanfiveprovinces

regulatedTCMpractitionersinCanada.TCMacupuncturewasnotrecognizedasan

importanthealthserviceandhadnoGST/HSTexemptionbythefederalgovernmentuntil

Feb2014.161Today,TCMisstillnotregulatedinallprovincesandterritories.TCMpractice

isdifficulttostandardize.ThequalityofTCMcareisnotuniform.Itvariesamong

practitioners,communitiesandacrossCanada.ItisnotjustifiabletoincludeTCMas

insuredhealthserviceinmedicaretoday.Nevertheless,TCMisgainingglobalpopularity.162,

163,164TCMisexpectedtoprogressandgrowinCanada.Soonenough,wemayneedtoask

ifTCMshouldbeaninsuredhealthservice,andonwhatmoralgrounds?

159‘HistoryofCMAAC|C.M.A.A.C.–PromotionTCMandAcupuncture’,accessed22October2017,http://www.cmaac.ca/history-of-cmaac.160WeiYuan,‘AcupunctureComestoCanada:TheStruggleforProfessionalRecognition,1970-1996.’(UniversityofOttawa(Canada),2001),http://dx.doi.org/10.20381/ruor-14751.161DepartmentofFinanceGovernmentofCanada,‘Archived-GovernmentofCanadaExemptsAcupuncturists’andNaturopathicDoctors’ProfessionalServicesfromGST/HST’,mediarelease,28March2014,https://www.fin.gc.ca/n14/14-047-eng.asp.162‘ARCHIVED-NaturalHealthProductsinCanada-AHistory’,aem,30December2002,https://www.canada.ca/en/health-canada/services/drugs-health-products/natural-non-prescription/regulation/history.html.163AmericanAssociationfortheAdvancementofScience,‘TheArtandScienceofTraditionalMedicinePart1:TCMToday—ACaseforIntegration’,Science346,no.6216(19December2014):1569–1569,https://doi.org/10.1126/science.346.6216.1569-d.164‘WHO|WHOTraditionalMedicineStrategy:2014-2023’,WHO,accessed3May2018,http://www.who.int/medicines/publications/traditional/trm_strategy14_23/en/.

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Nosinglemoraltheoryiscapableofresolvingallproblemsofjustice.Beauchampand

Childresssummarizethat:

...severaltypesoftheoryhavebeeninfluential:Utilitariantheoriesemphasizea

mixtureofcriteriaforthepurposeofmaximizingpublicutility;libertariantheories

layemphasisonindividualrightstosocialandeconomicliberty,whileinvokingfair

proceduresasthebasisofjustice,ratherthansubstantiveoutcomessuchas

increasesofwelfare;communitariantheoriesunderscoreprinciplesofjustice

derivedfromconceptionsofthegooddevelopedinmoralcommunities;and

egalitariantheoriesemphasizeequalaccesstothegoodsinlifethateveryrational

personvalues,ofteninvokingmaterialcriteriaofneedandequality.165

ConsideringthefactthatCanada’smedicareisasingle-payersystemandourfederal

governmentusesCanadaHealthTransfertosupportprinciplessuchasuniversality,

accessibilityandpublicadministration,medicarereflectsthenotionofegalitarianism.

Nevertheless,Floodpointsoutthat“HealthpolicyinCanadahaslongbeendominatedby

economistswhoseworkassumestheuniversalityofautilitarianapproachanddoesnot

allowforotherimportantCanadianvaluessuchasequality.”166Inthefaceoflimited

resources,utilitarianismisanothercompetingmoralperspectiveinourhealthcarepolicy.

Inherpolicyrecommendationforajustmedicare,Floodrecommendstheconsiderationof

multipleperspectives.Forthecontentsofamedicarebasket,shesuggeststhatthedecision

shouldbeafunctionof:165Beauchamp,PrinciplesofBiomedicalEthics,252.166Floodetal.,JustMedicareWhat’sin,What’sout,HowWeDecide,451.

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1. values;

2. availableresources;and

3. relativecostsandhealthbenefits.167

Eachethicaltheorycontributes“partialandoverlappingresources,notdefinitive,

exhaustivetruths.”168Competingtheoriescanilluminatedifferentquestionsand

sometimessupplementeachotherinacomplexmoraldeliberation.169Sincecosts,benefits

andvaluesareprominentfactorsinmedicarepolicy,Ishouldreflectonthequestionof

TCMcoveragewithtwodifferentsetsoflenses:utilitarianismandthefoundingvaluesof

medicare.

UtilitarianismandCost-BenefitAnalysis

BoetzkesandWaluchowpointoutthat“Mill’sutilitarianismisanancestorofmodern

theoriesofcost-benefitanalysis,whichareassuminganever-increasingrolein

controversiessurroundingtheallocationofmoneytovariousformsofhealthcare.”170Cost-

benefitanalysisinhealthcareistheanalysisofhealthcareresourceexpendituresrelativeto

possiblemedicalbenefits.Theanalysishelpspolicymakerstosetprioritieswhenchoices

mustbemadeinthefaceoflimitedresources.

167Floodetal.,‘DefiningtheMedicare“Basket”’,6.168SusanSherwin,‘Foundations,Frameworks,Lenses:TheRoleofTheoriesinBioethics’,Bioethics13,no.3–4(1July1999):203,https://doi.org/10.1111/1467-8519.00147.169Sherwin,‘Foundations,Frameworks,Lenses’.170ElisabethAiriniBoetzkesandWilfridJ.Waluchow,ReadingsinHealthCareEthics(Peterborough,Ont.:BroadviewPress,2002),11.

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UtilitarianismbeginswiththeideaofJeremyBenthamthat“thefoundationofmorals,

Utility,ortheGreatestHappinessPrinciple,holdsthatactionsarerightinproportionas

theytendtopromotehappiness,wrongastheytendtoproducethereverseof

happiness.”171Milladdsthat:

...thehappinesswhichformstheutilitarianstandardofwhatisrightinconduct,is

nottheagent’sownhappiness,butthatofallconcerned.Asbetweenhisown

happinessandthatofothers,utilitarianismrequireshimtobestrictlyimpartialasa

disinterestedandbenevolentspectator.172

Socialutilityoutweighsthehappinessofanindividualinutilitarianism.Therightactionis

theactionthatcanachievethe“greatesthappinessforthegreatestnumbersofpeople.“173

Haresummarizesthethreeconstituentsofutilitarianismasconsequentialism,welfarism

andaggregationism:

...asconstituentsofutilitarianism,consequentialism–thatis,theviewthatitistheir

consequencesthatdeterminethemoralityofactions–andwelfarism–thatis,the

viewthattheconsequencesthatwehavetoattendtoarethosethatconducestothe

welfareofthoseaffectedortheopposite.Theremainingconstituentisaviewabout

thedistributionofthiswelfare.Itistheviewthatwhen,asusually,wehaveachoice

betweenthewelfareofonelotofpeopleandthewelfareofanotherlot,weshould

choosetheactionwhichmaximizesthewelfare(i.e.,maximallypromotesthe

171John Stuart Mill, Utilitarianism, Oxford Philosophical Texts (Oxford [England] ; New York: Oxford University Press, 1998), 55.172Mill,64.173JosephPersky,‘PoliticalEconomyofProgress:JohnStuartMillandModernRadicalism-OxfordScholarship’,1July2016,http://www.oxfordscholarship.com/view/10.1093/acprof:oso/9780190460631.001.0001/acprof-9780190460631.

83

interests)ofallinsum,orinaggregate.Wemaycallthisconstituent

aggregationism.174

Throughthelensofutilitarianism,Ifindexamplesofhowamedicarepolicycanmaximize

theaggregateutilityfortheCanadiansociety.Forexample,itbecomesjustifiableforthe

governmenttoprioritizebuildinghospitalsincitycentreswithhighpopulationdensities

insteadofremotelocationswithlittletransportationaccess.Likewise,itisreasonableto

expectuniversalmedicaretofundvaccinationsforcommondiseasessuchasinfluenzafor

allresidentsbutnotatallforvaccinesoftraveldiseasessuchasyellowfeverorHepatitisB.

ThesustainabilityofCanada’smedicareisanaggregatesocialutilityandtheaccessibilityof

TCMtreatmentforonepersonisanindividualutility.Accordingtoutilitarianism,the

sustainabilityofCanada’smedicareshouldhavepriorityovertheaccessofTCMtreatment

foroneperson.Romanowclaimsthatthesustainabilityofmedicare:

...reliesonachievingtherightbalanceamongtheservicesthatareprovided,the

healthneedsofCanadians,andtheresourceswearepreparedtocommittothe

system.Findingthatbalanceisuptothosewhogovernthehealthcaresystem–

individualCanadians,communities,healthcareproviders,healthauthoritiesand

hospitaladministrators,andgovernments.Thedecisionstheymaketogetherwill

determinewhetherornotthesystemissustainableinthefuture.175

174R.M.Hare,‘AUtilitarianApproach’,inACompaniontoBioethics,ed.HelgaKuhseandPeterSinger(Wiley-Blackwell,2009),87,https://doi.org/10.1002/9781444307818.ch9.175Romanow,BuildingonValuestheFutureofHealthCareinCanada,44.

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In2010,DrummondpresentedaproposalforsustainablehealthcareinOntario.He

explainsadeeperproblemfortheincreasingcostsofhealthcare:

...undercontinuationofthe‘statusquo’,Ontario’spublichealthcarespendingwill

increaseatleast6.5%annuallywellintothefuture.Incontrast,weprojectlonger-

termgrowthinOntario’snominalGDPandrevenues,intheabsenceoftaxrate

increases,tobearound4%.Oncefiscalbalanceisrestored,Ontariomustcontainthe

growthinoverallprogramspendingtothepaceofrevenuecollections.Ifhealthcare

spendingroarsaheadat6.5%perannumwhiletotalspendingiscontainedto4%

growth,thenhealthcarewouldcomprise80%oftotalprogramspendingby2030,

upfrom46%today.Everythingelsethegovernmentdoes,includingproviding

educationforitsresidents,wouldhavetobesqueezedintotheremainingone-fifth.

Clearlyitisnotfeasibletofulfilltheobligationsoftheprovinceandtheaspirations

ofitspeoplewithsuchabudget.Somethingmustgive.176

Iagreethatsomethinghastogive.ButasFloodsuggests,thedecisionprocessshouldbea

moretransparentandinclusiveprocedureforstakeholders.Thedecisionsshouldbebased

onmedicalneed,evidenceofefficacy,andcosts.177, 178Inaddition,Floodalsosuggeststhat:

...medicalopportunitycostbeasecondnecessarycriterionfordefiningthecontents

ofthebasket,inadditiontomedicalnecessity.Wedefinemedicalopportunitycost

tobethecomparativecontributiontohealthforgonebyexcludingagiven

servicefromthebasket.179

176Drummond,‘ChartingaPathtoSustainableHealthCareinOntario:10ProposalstoRestrainCostGrowthwithoutCompromisingQualityofCare-ScholarsPortalBooks’,6.177ColleenM.Floodetal.,‘Read-DefiningtheMedicare“Basket”’,ii,accessed4February2018,http://www.deslibris.ca.proxy.bib.uottawa.ca/ID/250981.178Floodetal.,JustMedicareWhat’sin,What’sout,HowWeDecide,449–54.

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TojustifyaTCMtreatmentbeinganinsuredhealthservice,autilitarianapproachwould

requireTCMtopresentmoreevidenceofefficacy,favourablecost-benefitanalysis,and

positivemedicalopportunitycost.Thesubsequentquestionsaboutevidenceforwhich

TCMtreatment,howtoevaluatethebenefitandhowtoassessthecostareoutsidethe

scopeofmythesisandexpertise.However,IsuggesttwoTCMclinicalcharacteristicsthat

areworthyofinvestigationinthefuture.

First,aTCMclinicgenerallyhaslessdemandformedicalequipment,technology,spaceand

labourincomparisontoaprimarycareoracutecareclinic.Thischaracteristicimplies

savingsonoperatingcosts.ItalsomakessettingupaTCMclinicrelativelyfast.Sincerural

areasoftenhaveashortageofconventionalmedicalclinics,thecost-benefitanalysisof

supplementingaruralcommunityclinicwithaTCMclinicisworthyofinvestigation.

Second,TCMisstrongindiseaseprevention.Forexample,intreatingheadaches,TCM

practitionersaimatpreventingaheadachefromre-occurring.Similarly,TCMusesthe

preventativeapproachtotreatdiseasessuchasheartdiseases,digestivediseasesand

cancerthatarecommondiseasesinCanada.Intuitively,apreventativeapproachismore

cost-effectiveinmedicine.Sometargetedcost-benefitanalysesofTCMtreatmentshave

alreadyshownpositiveresults.180181However,thequantityofresearchisstillrelatively

179Floodetal.,‘DefiningtheMedicare“Basket”’,13.180YiLietal.,‘Cost-EffectivenessAnalysisofCombinedChineseMedicineandWesternMedicineforIschemicStrokePatients’,ChineseJournalofIntegrativeMedicine20,no.8(1August2014):570–84,https://doi.org/10.1007/s11655-014-1759-9.181L.Sunetal.,‘PCV34-TheCost-EffectivenessofFourChinesePatentMedicineintheTreatmentofAnginaPectorisinChina’,ValueinHealth17,no.7(1November2014):A761,https://doi.org/10.1016/j.jval.2014.08.261.

86

smallincomparisontobiomedicine.MostoftheresearchalsotookplaceoutsideofCanada

andmaynotbeapplicableinCanada.ThisimpliesthatmoreTCMresearchdataisneeded

fromlocalpractitionersandpatients.Themedicalopportunitycostofexcludingany

preventativemedicinesuchasTCMisalsoworthyofinvestigation.

ValuesofEquity,FairnessandSolidarity

Costsareimportant.Soarevalues.Valuesdeterminenotonlythestructureorserviceof

medicarebut,alsothekindofsocietythatwewanttolivein.

Inhisreport,Romanowstatesthat:

...intheirdiscussionswithme,Canadianshavebeenclearthattheystillstrongly

supportthecorevaluesonwhichourhealthcaresystemispremised–equity,

fairnessandsolidarity.Thesevaluesaretiedtotheirunderstandingofcitizenship.

Canadiansconsiderequalandtimelyaccesstomedicallynecessaryhealthcare

servicesonthebasisofneedasarightofcitizenship,notaprivilegeofstatusor

wealth...Theywantandexpecttheirgovernmentstoworktogethertoensurethat

thepoliciesandprogramsthatdefinemedicareremaintruetothesevalues.182

Equity,fairnessandsolidarityarethefoundingvaluesofCanada’smedicare.Canadians

supportuniversalaccesstoprimaryhealthcareservicesbasedonmedicalneed,notthe

abilitytopay.AlthoughCanadiansarenotindifferentaboutthemedicarebenefitsandcosts,

wewanttoliveinasocietythateveryonefeelsobligatedtocareforthesickandtheinjured.

182Romanow,BuildingonValuestheFutureofHealthCareinCanada,xvi.

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AsRawls,oneofthemostimportantpoliticalphilosophersofthe20thcentury,suggests,

“Injusticeasfairnessmenagreetoshareoneanother’sfate.Indesigninginstitutionsthey

undertaketoavailthemselvesoftheaccidentsofnatureandsocialcircumstancesonly

whendoingsoisforthecommonbenefit.”183Canadianvaluesfosterahighlevelofsecurity,

stabilityandsocialcooperationinthesociety.Everymemberofthesocietycanexpectafair

opportunitytoleadadecentlife.Canadiancitizenshipistheenvyofmanypeopleinthe

world.

IaskiftheexclusionofTCMfrominsuredhealthservicecontradictsthecorevaluesof

medicare?Thereisnoconsensusonthedefinitionsofequity,fairnessorsolidarityin

medicare.184, 185, 186Lanoixexplainsthatequityistiedtonon-discrimination,fairness

relatestotheadequacyofmedicalservicesandtheprincipleofsolidaritypointstoashared

goal.187Itakethelibertytoapplyherinterpretationsinthefollowingdiscussion.My

argumentisthatiftheexclusionofTCMfrominsuredhealthservicecontradictsanyoneof

theaboveinterpretations,theexclusionisnotjustified.

Ifoundanexampleofinequityintheacupuncturetreatmentforphysicalrehabilitation.

Acupuncturetreatmentisacommontherapyinphysicalrehabilitation.Ifapatientreceives

acupuncturetreatmentfromaphysicianornurseinahospital,thetreatmentisdeemed183JohnRawls,ATheoryofJustice,2ndprinting..(Cambridge,Mass.:BelknapPressofHarvardUniversityPress,1972),102.184Romanow,BuildingonValuestheFutureofHealthCareinCanada.185Daniels,JustHealthCare.186Floodetal.,‘DefiningtheMedicare“Basket”’.187MoniqueLanoix,‘NoLongerHomeAlone?HomeCareandtheCanadaHealthAct’,HealthCareAnalysis25,no.2(1June2017):177–82,https://doi.org/10.1007/s10728-016-0336-0.

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medicallynecessaryandiscoveredundermedicare.However,ifapatientreceivesthe

sameacupuncturetreatmentfromaphysiotherapistorTCMpractitionerinaprivateclinic,

thetreatmentisexcludedfrominsuredhealthserviceofmedicare.Thepatientwillhaveto

payout-of-pocketexpenses.Ifequityistiedtonon-discrimination,thenthediscrimination

ofproviderintheacupuncturetreatmentcontradictstheprincipleofequity.Thereis

similardiscriminationintheprivatehealthinsurancesector.Withsomeprivatehealth

insuranceplans,apatientwhopaysforacupuncturetreatmentsperformedbyaphysician

ornursewillbereimbursed.However,underthesameprivatehealthinsuranceplans,

anotherpatientwhopaysforthesameacupuncturetreatmentperformedbyaTCM

practitionerwillnotbereimbursed.Butprivatehealthplansareoutsidethescopeofmy

discussionhere.

Conventionalmedicinedoesnotalwaysworkforeverypatient.Somepatientsmay

experienceseveresideeffectsandsomemaynotrespondsufficientlytothemedicine.

ThereareexamplesfromtheverbatimresponsesinthesurveyinsectionII.The

participantswrote:

• “veryeffectiveforcervicaldystoniaincombinationwithBotoxthatIreceiveatCivic

Hospital”

• “Becausemymotherdiditinthepast.SoIdecidetotrybecauseIwastakingtoo

muchpainkiller.Now,Ireduced3/4ofmypainkiller.Myhandsarenolonger

swellinginthemorning,IhavemoreenergyandIfeelbetterinmybody.”

• “BecauseI'vehadsuccesswithitinthepastfortreatmentofmychronicpain

condition.”

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• “Ibelieveinanaturalwayofhealingdiseases.IamnotagainstWesternmedicine,

butthroughmyexperience,TCMhelpsmealotofregainingmystrengthand

generalhealth.”

Forthesepatients,TCMisaneffectivecomplementarymedicinetotheconventional

medicine.Iffairnessrelatestotheadequacyofmedicalservices,medicareshouldrecognize

theirhealthneedsofusingTCMasacomplementarymedicine.Theconceptsofhealth

needsarenotmerelymedicalnecessityasintheCanadaHealthAct.188, 189,190TheRoyal

CollegeofPhysiciansandSurgeonsofCanadaconsidersahealthneedtobethegap

betweenacurrentstateofhealthandadesirablestateofhealth.191Apatient-perceived

healthneedcanhintanunfilledgapbyourconventionalhealthcare.Itpromptsquestions

suchas“whatcausesthegap”and“howdoweclosethegap?”

Inherpolicyreport,Floodrecommendsthat“anadditionalcategoryofcoverageshouldbe

considered,onalimitedandexperimentalbasis,forenhancedalternativestoservices

withinthepubliccore,offeredonaprivatebasiswithinacloselyregulatedframework.”192

EveniftheTCMtreatmentsforthesepatientsinthisnewcategorymayincursomeout-of-

pocketexpenses,itisanimportantsteptorecognizetheirhealthneeds.Inaddition,

patientswithspecialhealthneedsmaybemoredesperateandthereforeespecially188John R Wilkinson and Scott A Murray, ‘Assessment in Primary Care: Practical Issues and Possible Approaches’, BMJ : British Medical Journal 316, no. 7143 (16 May 1998): 1524–28.189John Wright, Rhys Williams, and John R Wilkinson, ‘Development and Importance of Health Needs Assessment’, BMJ : British Medical Journal 316, no. 7140 (25 April 1998): 1310–13.190QualityImprovementandInnovationPartnership,‘NeedsAssessmentResourceGuideforFamilyHealthTeams’,January2009,www.qiip.ca.191TheRoyalCollegeofPhysiciansandSurgeonsofCanadaandLisaLittleConsulting,‘DefiningSocietalHealthNeedsRoyalCollegeDefinitionandGuide’,April2012,royalcollege.ca.192Floodetal.,‘DefiningtheMedicare“Basket”’,4.

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vulnerabletounethicalpractice.HavingtheirTCMtreatmentscoveredundera“closely

regulatedframework”isbeneficialtovulnerablepatients.Forexample,theframeworkcan

mandatetheimplementationofthedeliberativemodelforTCMpractitioner-patient

relationshipasdiscussedinsectionIII.

Theaccessto“medicallynecessary”hospitalandphysicianservicesshouldbebasedon

medicalneed,nottheabilitytopay.193Ifsolidaritypointstoasharedgoal,thecommongoal

isthatanyonewhoneedsamedicaltreatmentwillgetthemedicaltreatment,andall

membersofoursocietysharethecosts.ForthosewhosupportTCM,imaginereplacing

“medicaltreatment”by“TCMtreatment”inthepreviousstatement.Itistheidealsolution

forequalaccesstoTCMinCanada.However,forthetimebeing,accesstoTCMcarecanbe

difficultforsomeTCMpatients.AparticipantinthesurveyofsectionIIwrotethe

following:

AsIamamicabletoholisticapproachestomedicine,IfindthatTCMhelpsmy

physicalailmentstremendously.However,oneofthebiggestissuesis

mainstreammedicinenotacceptingorbelievinginTCMandinsurance

companiesnotprovidinganycoverageforsuchtreatments.Thesetwoareasare

themostfrustratingwhichdecreasesmychancestoseekTCMtreatments.

Ideally,evenifnotevidence-based,mainstreamdoctorsandinsurersshouldgive

theirpatients/clientsthefreedomtochooseortoseektreatmentsthathelp

themfeelbetterorhealfaster.

193Floodetal.,i.

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PerhapsthisshouldpromptustoaskwhatkindofTCMcommunitiesdowewantto

developintheinterim?IfsolidarityexistsinaTCMcommunity,thenitshouldimplythat

themembersgetunitedandorganizeaTCMcommunityclinictoassistthosewhoneed

TCMtreatmentbutcannotaffordit.

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Conclusion

Non-evidence-basedmedicineisnottheequivalentofnoevidenceorshammedicine.

Nevertheless,non-evidence-basedmedicineimpliescertainclinicalrealitiesand

constraints.Inthisthesis,IfocusedontheTCMethicalissuesthatareparticularlyrelated

tothenatureofnon-evidence-basedmedicine.Inapplyingtheethicalframeworkof

principlism,IidentifiedthreepotentialethicalissuesinthepracticeofTCMinCanada.I

alsomadesuggestionstoresolvethem.

InresearchinghowtoenableTCMpatientstomakeamoreinformeddecisiontouseTCM,I

conductedanempiricalstudy.ThestudyexaminedtheimpactofTCMbeingnon-evidence-

basedmedicineonparticipants’decision-making.Itusesqualitativeanalysisandthe

resultshasnostatisticalpowertomakegeneralizationbeyondthesmallsample.Among

theparticipants,theawarenessofTCMbeingnon-evidence-basedmedicineiscorrelated

withtheexperienceofusingTCM:

• ParticipantswhohadmoreTCMexperiencewereoftenawareofTCMbeingnon-

evidence-based.Butthisknowledgehadlittleimpactonthedecisionofthisgroupto

useTCM.Itisimportanttoconscientiouslyremindthisgroupofpatientstobalance

thepotentialbenefitsofTCMwiththeuncertainties.

• ParticipantswithlessexperiencewithTCMshowedlessawarenessofTCMbeing

non-evidence-based.Theyalsoexpressedmoreconsiderationsofrisksinadditionto

thebenefitsofusingTCM.TheexplicitdisclosureofTCMbeingnon-evidence-based

93

medicinewouldbematerialtotheirdecisiontouseTCM.Therefore,thenon-

evidence-baseddisclosureshouldbepartoftheinformedconsentprocessforthis

groupbeforetreatment.ItcanhelpthenewTCMpatientstomakeamoreinformed

decisionandsettherightexpectationofTCMaccordingly.

• Themajorityofparticipantsprioritizedtheprinciplesofbeneficenceover

nonmaleficenceinTCM.TheTCMpatientsamongtheparticipantstendedto

prioritizethepotentialbenefitsovertherisksofusingTCM.Thispatient

characteristicpointstothevulnerabilitytounethicalpractice.

• SomeparticipantsofthesurveyindicatedtheirneedstouseTCMtocomplement

conventionalmedicine.Mysmallsurveysuggeststhatalargerscaleresearchto

studyabiggerpopulationisfeasibleandnecessary.ItisimperativeformoreTCM

practitionerstoconductempiricalstudiesintheircommunitiestounderstandthe

needsandexpectationsofTCMpatients.ThepotentialfindingscanhelptheTCM

practitionerstoimprovethequalityofTCMcare.

ThesafetyandefficacyofTCMinCanadarelyontheethicalstandardsandcompetencyof

TCMpractitioners.Emphasisonmoralcultivationandtheidealpractitioner-patient

relationshipmodelinTCMeducationcaneffectivelypromotehighTCMstandardsof

practiceforthelong-term.TheTCMeducationsystemshouldconsidertheintegrationof

theteacher-apprenticelearningmodelintotheinstitutionalmodel.Besidesbeingeffective

inethicseducation,theteacher-apprenticelearningmodelalsopromotesstudentselection,

intensiveclinicalpracticeandcanfacilitateTCMcontinuingeducationamongpractitioners.

94

Thecurrentdecision-makingframeworkformedicare’sinsuredhealthserviceisnot

adequate.Thecoverageofmedicareserviceisnotnecessarilyfairtoday.Withrespectto

whetherTCMshouldbeaninsuredhealthservice,utilitarianismpointstotheneedfor

cost-benefitanalysisandmedicalopportunitycostforthejustificationofTCMcoverage.

EquityandfairnessjustifytheconsiderationofsomecoverageofTCMcareasa

complementarymedicinetotheconventionalhealthcare.SolidaritypromptsTCM

communitiestoorganizecommunityclinicsinordertoofferaffordableTCMcareinthe

interim.

NotwithstandingthatTCMisnon-evidence-basedmedicineandhasqualitycontrolissues,

TCMpractitionerswitnessevidencethatsupportsthebenefitsofTCMinhealthcare.The

surveyofsectionIIshowedsomeexamples.Althoughthesamplesizeissmall,thedata

indicatethatsomehealthneedscanbemetbyTCMasacomplementarymedicine.Itis

imperativeforresearchersandclinicianstofurtherinvestigatethebestTCMpracticesand

mostproductivewayforTCMtocomplementtheconventionalhealthcare.Ihavesuggested

severalresearchareasthatareworthyoffurtherinvestigationsbutoutsidethescopeof

thisthesis:

• TheneedsandexpectationofTCMpatientsacrossCanada

• GuidelinesandmethodsforTCMpractitionerstoperformduediligenceonTCM

therapies

• Cost-benefitanalysisandmedicalopportunitycostanalysisforthecommonTCM

therapiesinCanada

TheresearchfindingsmayhelpimprovethequalityofTCMcareinCanada.

95

Inthecontextofmoraltheory,MacIntyreassertsthat:

...atraditionissustainedandadvancedbyitsowninternalargumentsandconflicts.

Andevenifsomelargepartsofmyinterpretationcouldnotwithstandcriticism,the

demonstrationofthiswoulditselfstrengthenthetraditionwhichIamattemptingto

sustainandtoextend.194

Byputtingforwardmythoughtsandsuggestionsinthisthesis,Iintendtocontinuethe

researchanddevelopmentofTCMinCanada.

194AlasdairC.MacIntyre,AfterVirtue:AStudyinMoralTheory,3rded..(NotreDame,Ind.:UniversityofNotreDamePress,2007),260.

96

AppendixASurveyPackage

AppendixAcontainsfouritems:

• TheSaintPaulUniversityResearchEthicsBoardapproval(REBFileNumber:

1360.6/17)certificate

• Theinvitationlettertosurveyparticipants

• Theimpliedconsentformtosurveyparticipants

• Thequestionnairetosurveyparticipants

97

Bureau de la recherche et de la déontologie Office of Research and Ethics

Université Saint Paul University | 223, Main Ottawa (Ontario) Canada K1S 1C4 613 236-1393 Télécopie / Fax 613 782-3005

1/1

03-10-2017 dd-mm-yyyy

Ethics Certificate Research Ethics Board (REB)

REB File Number 1360.6/17 Principal Investigator / Thesis supervisor / Co-investigators / Student

Last name Name Affiliation Role

Fok Winnie Faculty of Philosophy Student-Principal Investigator

Lanoix Monique Faculty of Philosophy Thesis Supervisor Type of project MA Thesis Title An Insider View of Ethical Issues in Traditional Chinese Medicine in Canada

Approval date Expiry Date Decision

03-10-2017 02-10-2018 1 (approved) (dd-mm-yyyy) (dd-mm-yyyy)

Committee comments:

The Research Ethics Board (REB) approved the project. The researcher is invited to use the reference number 1360.6/17 when recruiting participants.

In accordance with the Tri-Council Policy Statement, the Saint Paul University Research Ethics Board has examined and approved the application for an ethics certificate for this project for the period indicated and subject to the conditions listed above. The research protocol may not be modified without prior written approval from the REB. This includes, among others, the extension of the research, additional recruitment for the inclusion of new participants, changes in location of the fieldwork, any stage where a research permit is required, such as work in schools. Minor administrative changes are allowed.

The REB must be notified of all changes or unanticipated circumstances that have a serious impact on the conduct of the research, that relate to the risk to participants and their safety. Modifications to the project, information, consent and recruitment documentation must be submitted to the Office of Research and Ethics for approval by the REB.

The investigator must submit a report four weeks prior to the expiry date of the certificate stated above requesting an extension or that the file be closed.

Documents relating to publicity, recruitment and consent of participants should bear the file number of the certificate. They must also indicate the coordinates of the investigator should participants have questions related to the research project. In which case, the documents will refer to the Chair of the REB and provide the coordinates of the Office of Research and Ethics.

Signature

Louis Perron Chair Research Ethics Board (REB)

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100

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WorksCited‘AboutNaturalHealthProducts’.aem,26November2010.

https://www.canada.ca/en/health-canada/services/drugs-health-products/natural-non-prescription/regulation/about-products.html.

‘AboutTCM·CTCMPAOWebsite’.Accessed28September2017.https://www.ctcmpao.on.ca/public/about-tcm/.

‘AcupunctureforFibromyalgia|Cochrane’.Accessed17March2018.https://doi.org/10.1002/14651858.CD007070.pub2.

‘AcupunctureforStrokeRehabilitation|Cochrane’.Accessed17March2018.https://doi.org/10.1002/14651858.CD004131.pub3.

Andrews,Bridie.TheMakingofModernChineseMedicine,1850-1960.ContemporaryChineseStudies.VancouverBritishColumbia:UBCPress,2013.https://login.proxy.bib.uottawa.ca/login?url=http://books.scholarsportal.info/viewdoc.html?id=/ebooks/ebooks3/upress/2014-06-27/1/9780774824347.

‘ARCHIVED-NaturalHealthProductsinCanada-AHistory’.aem,30December2002.https://www.canada.ca/en/health-canada/services/drugs-health-products/natural-non-prescription/regulation/history.html.

Aristotle.Aristotle:NicomacheanEthics.TranslatedbyRogerCrisp.2edition.NewYork:CambridgeUniversityPress,2014.

Beauchamp,TomL.PrinciplesofBiomedicalEthics.7thed..NewYork:OxfordUniversityPress,2013.

———.‘TheTheory,Method,andPracticeofPrinciplism’,16July2015.https://doi.org/10.1093/oxfordhb/9780198732365.013.31.

Birkelund,Regner.‘EthicsandEducation’.Accessed13October2017.https://journals-scholarsportal-info.proxy.bib.uottawa.ca/details/09697330/v07i0006/473_eae.xml.

Bleiberg,DarshakSanghaviandSarah.‘CanCanadian-StyleHealthcareWorkinAmerica?VermontThinksSo.’Brookings(blog),30November2001.https://www.brookings.edu/blog/up-front/2014/01/22/can-canadian-style-healthcare-work-in-america-vermont-thinks-so/.

Boetzkes,ElisabethAirini,andWilfridJ.Waluchow.ReadingsinHealthCareEthics.Peterborough,Ont.:BroadviewPress,2002.

Boudreau,J.‘TheHumanitiesinMedicalEducation:WaysofKnowing,DoingandBeing’.JournalofMedicalHumanities36,no.4(1December2015):321–36.

Braun,Virginia,andVictoriaClarke.‘UsingThematicAnalysisinPsychology’.QualitativeResearchinPsychology3,no.2(2006):77–101.https://doi.org/10.1191/1478088706qp063oa.

Buring,Julie.‘WhyAreClinicalTrialsImportant?Lecture|WhyAreClinicalTrialsImportant?|HSPH-HMS214xCourseware|EdX’.Accessed23October2017.https://courses.edx.org/courses/HarvardX/HSPH-HMS214x/2013_SOND/courseware/aa057b54817048a29ecd50c1ae205c79/7c39039dd1e747a69c49f3009927ae6d/?child=first.

Canada,Health,andHealthCanada.‘AboutNaturalHealthProducts’.Organizationaldescriptions.aem,26November2010.https://www.canada.ca/en/health-

104

canada/services/drugs-health-products/natural-non-prescription/regulation/about-products.html.

———.‘CanadaHealthAct’.Navigationpage.aem,26July2004.https://www.canada.ca/en/health-canada/services/health-care-system/canada-health-care-system-medicare/canada-health-act.html.

Chiang,Howard.HistoricalEpistemologyandtheMakingofModernChineseMedicine.ManchesterUniversityPress,2015.

CMA.‘CodeofEthics’.https://www.cma.ca/En/Pages/code-of-ethics.aspx.Accessed25March2017.https://www.cma.ca/En/Pages/code-of-ethics.aspx.

‘Cost–BenefitAnalysisandHealthCareEvaluations,SecondEdition’,28November2014.https://www-elgaronline-com.proxy.bib.uottawa.ca/view/9781781004586.xml.

Daniels,Norman.JustHealthCare,c1985.DeFranzo,Susan.‘DifferencebetweenQualitativeandQuantitativeResearch.’SnapSurveys

Blog,16September2011.https://www.snapsurveys.com/blog/qualitative-vs-quantitative-research/.

Drummond,Don.‘ChartingaPathtoSustainableHealthCareinOntario:10ProposalstoRestrainCostGrowthwithoutCompromisingQualityofCare-ScholarsPortalBooks’.Accessed4December2017.http://books2.scholarsportal.info.proxy.bib.uottawa.ca/viewdoc.html?id=/ebooks/ebooks1/gibson_chrc/2010-08-20/1/10397929#tabview=tab1.

‘EducationProgramReview|CTCMA-CollegeofTraditionalChineseMedicinePractitionersandAcupuncturists’.Accessed23October2017.http://www.ctcma.bc.ca/resources/education-program-review/.

Emanuel,EzekielJ.,andLindaL.Emanuel.‘FourModelsofthePhysician-PatientRelationship’.JAMA267,no.16(22April1992):2221–26.https://doi.org/10.1001/jama.1992.03480160079038.

Floodetal.,ColleenM.‘DefiningtheMedicare“Basket”’.Accessed4February2018.http://www.deslibris.ca.proxy.bib.uottawa.ca/ID/250981.

———.JustMedicareWhat’sin,What’sout,HowWeDecide.CanadianElectronicLibrary.BooksCollection.Toronto[Ont.],Toronto:UniversityofTorontoPress,2006.https://login.proxy.bib.uottawa.ca/login?url=http://site.ebrary.com/lib/oculottawa/Doc?id=10219133.

Friedman,LawrenceM.,CurtD.Furberg,andDavidL.DeMets.FundamentalsofClinicalTrials.NewYork,NY:SpringerNewYork,2010.https://doi.org/10.1007/978-1-4419-1586-3.

GovernmentofCanada,DepartmentofFinance.‘Archived-GovernmentofCanadaExemptsAcupuncturists’andNaturopathicDoctors’ProfessionalServicesfromGST/HST’.Mediarelease,28March2014.https://www.fin.gc.ca/n14/14-047-eng.asp.

———.‘CanadaHealthTransfer’.Federaltransfers,1January2000.https://www.fin.gc.ca/fedprov/cht-eng.asp.

———.‘FederalSupporttoProvincesandTerritories’.Federaltransfers,15December2014.https://www.fin.gc.ca/fedprov/mtp-eng.asp#Ontario.

Guestetal.,Greg.AppliedThematicAnalysis.LosAngeles:SagePublications,2012.https://login.proxy.bib.uottawa.ca/login?url=http://methods.sagepub.com/book/applied-thematic-analysis.

105

Guyatt,Gordon.‘Evidence-BasedMedicine:ANewApproachtoTeachingthePracticeofMedicine’.JAMA268,no.17(4November1992):2420.https://doi.org/10.1001/jama.1992.03490170092032.

Hansen,Chad.‘HumanityandNatureinChineseThought|中国哲学思想中的人类与自然 |EdX’.Accessed26October2017.https://www.edx.org/course/humanity-nature-chinese-thought-zhong-hkux-hku03x.

Hare,R.M.‘AUtilitarianApproach’.InACompaniontoBioethics,editedbyHelgaKuhseandPeterSinger,85–90.Wiley-Blackwell,2009.https://doi.org/10.1002/9781444307818.ch9.

Higgins,Christopher,andKatherineJo.‘EthicsandEducation-Education-OxfordBibliographies-Obo’.Accessed13October2017.http://www.oxfordbibliographies.com.proxy.bib.uottawa.ca/view/document/obo-9780199756810/obo-9780199756810-0142.xml;jsessionid=3B8BDC8023E0878C565A114823E6794B.

‘HistoryofCMAAC|C.M.A.A.C.–PromotionTCMandAcupuncture’.Accessed22October2017.http://www.cmaac.ca/history-of-cmaac.

HKBU.‘BachelorofChineseMedicineandBachelorofScience(Hons)inBiomedicalScience’.Accessed7November2017.http://scm.hkbu.edu.hk/en/education/undergraduate_programmes/bachelor_of_chinese_medicine_and_bachelor_of_science_Hons_in_biomedical_science/index.html.

‘JurisprudenceCourse·CTCMPAOWebsite’.Accessed28October2017.https://www.ctcmpao.on.ca/applicant/jurisprudence-course/.

Kameshwar,Prasad.‘FundamentalsofEvidenceBasedMedicine-Springer’.Accessed24September2017.https://link-springer-com.proxy.bib.uottawa.ca/book/10.1007/978-81-322-0831-0/page/1.

Lam,Wing,ScottBussom,andFulanGuan.‘TheFour-HerbChineseMedicinePHY906ReducesChemotherapy-InducedGastrointestinalToxicity|ScienceTranslationalMedicine’.Accessed6November2017.http://stm.sciencemag.org/content/2/45/45ra59.

Lan,Fengli.Culture,Philosophy,andChineseMedicine:VienneseLectures.CultureandKnowledge ;v.22.FrankfurtamMain ;NewYork:PeterLang,2012.

Lanoix,Monique.‘NoLongerHomeAlone?HomeCareandtheCanadaHealthAct’.HealthCareAnalysis25,no.2(1June2017):168–89.https://doi.org/10.1007/s10728-016-0336-0.

Leung,Siu-wai,andHaoHu,eds.Evidence-BasedResearchMethodsforChineseMedicine.Singapore:SpringerSingapore,2016.https://doi.org/10.1007/978-981-10-2290-6.

Li,Yi,Han-xuXi,ShaZhu,NaYu,JingWang,YanLi,Guo-peiYu,Xie-minMa,JunZhang,andLue-pingZhao.‘Cost-EffectivenessAnalysisofCombinedChineseMedicineandWesternMedicineforIschemicStrokePatients’.ChineseJournalofIntegrativeMedicine20,no.8(1August2014):570–84.https://doi.org/10.1007/s11655-014-1759-9.

Linn,YehChing.‘Evidence-BasedMedicineforTraditionalChineseMedicine:ExploringtheEvidencefromaWesternMedicinePerspective’.ProceedingsofSingaporeHealthcare20,no.1(1March2011):12–19.https://doi.org/10.1177/201010581102000103.

106

MacIntyre,AlasdairC.AfterVirtue:AStudyinMoralTheory.3rded..NotreDame,Ind.:UniversityofNotreDamePress,2007.

Madore,Odette.‘TheCanadaHealthAct:OverviewandOptions’.Accessed30November2017.https://lop.parl.ca/content/lop/researchpublications/944-e.htm#4insuredtxt.

Masic,Izet,MilanMiokovic,andBelmaMuhamedagic.‘EvidenceBasedMedicine–NewApproachesandChallenges’.ActaInformaticaMedica16,no.4(2008):219–25.https://doi.org/10.5455/aim.2008.16.219-225.

McColl,Alastair,HelenSmith,PeterWhite,andJennyField.‘GeneralPractitioners’PerceptionsoftheRoutetoEvidenceBasedMedicine:AQuestionnaireSurvey’.BMJ316,no.7128(31January1998):361–65.https://doi.org/10.1136/bmj.316.7128.361.

Merrill,SarahBishop.DefiningPersonhood:TowardtheEthicsofQualityinClinicalCare.ValueInquiryBookSeries ;v.70.Amsterdam ;Atlanta,Ga.:Rodopi,1998.

Mill,JohnStuart.Utilitarianism.OxfordPhilosophicalTexts.Oxford[England] ;NewYork:OxfordUniversityPress,1998.

Nie,Jing-Bao.MedicalEthicsinChina:ATransculturalInterpretation.BiomedicalLawandEthicsLibrary.London ;NewYork:Routledge,2011.

Normile,Dennis.‘TheNewFaceofTraditionalChineseMedicine’.Science299,no.5604(10January2003):188–90.https://doi.org/10.1126/science.299.5604.188.

‘NursingEthics’.Accessed1March2017.https://www.cna-aiic.ca/en/on-the-issues/best-nursing/nursing-ethics.

Oakley,Justin.‘AVirtueEthicsApproach’.InACompaniontoBioethics,editedbyHelgaKuhseandPeterSinger,91–104.Wiley-Blackwell,2009.https://doi.org/10.1002/9781444307818.ch10.

OCTCM.‘AcupunctureSchool|’.Acupunctureschool|OntarioCollegeofTCMToronto.Accessed7November2017.https://www.studytcm.ca.

OleDöring.‘8.4.TeachingMedicalEthicsinChina.Cultural,SocialandEthicalIssues’.Accessed28June2017.http://www.eubios.info/ABC4/abc4255.htm.

Ontario,Governmentof.‘PrivateCareerColleges(PCC)’.Accessed6February2018.http://www.tcu.gov.on.ca/pepg/audiences/pcc/private.html.

‘OxfordCentreforEvidence-BasedMedicine-LevelsofEvidence(March2009)’.CEBM,11June2009.https://www.cebm.net/2009/06/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/.

Persky,Joseph.‘PoliticalEconomyofProgress:JohnStuartMillandModernRadicalism-OxfordScholarship’,1July2016.http://www.oxfordscholarship.com/view/10.1093/acprof:oso/9780190460631.001.0001/acprof-9780190460631.

Polsky,Daniel,andHenryGlick.‘CostingandCostAnalysisinRandomizedControlledTrials:CaveatEmptor’.PharmacoEconomics27,no.3(2009):179–88.

‘PrivateTrainingInstitutionDirectory|PrivateTrainingInstitutionsBranch’.Accessed6February2018.https://www.privatetraininginstitutions.gov.bc.ca/students/pti-directory.

‘PublicRegisterSearch·CTCMPAOWebsite’.Accessed4October2017.https://www.ctcmpao.on.ca/publicregistersrc/.

107

QualityImprovementandInnovationPartnership.‘NeedsAssessmentResourceGuideforFamilyHealthTeams’,January2009.www.qiip.ca.

Rawls,John.ATheoryofJustice.2ndprinting..Cambridge,Mass.:BelknapPressofHarvardUniversityPress,1972.

‘Regulations·CTCMPAOWebsite’.Accessed6November2017.https://www.ctcmpao.on.ca/regulation/.

Romanow,RoyJ.BuildingonValuestheFutureofHealthCareinCanada:FinalReport.Saskatoon,Sask.:CommissionontheFutureofHealthCareinCanada,2002.https://login.proxy.bib.uottawa.ca/login?url=http://books.scholarsportal.info/viewdoc.html?id=/ebooks/ebooks0/gibson_cppc/2009-12-01/6/207365.

Sackettetal.,David.‘EvidenceBasedMedicine:WhatItIsandWhatItIsn&#039;t.1996’.Accessed1February2018.https://uottawa-primo.hosted.exlibrisgroup.com/primo_library/libweb/action/dlDisplay.do?vid=UOTTAWA&afterPDS=true&docId=TN_medline17340682&loc=adaptor,primo_central_multiple_fe.

Scheid,Volker.ChineseMedicineinContemporaryChinaPluralityandSynthesis.E-DukeBooksScholarlyCollection.Durham,NC:DukeUniversityPress,2002.https://login.proxy.bib.uottawa.ca/login?url=http://dx.doi.org/10.1215/9780822383710.

Science,AmericanAssociationfortheAdvancementof.‘TheArtandScienceofTraditionalMedicinePart1:TCMToday—ACaseforIntegration’.Science346,no.6216(19December2014):1569–1569.https://doi.org/10.1126/science.346.6216.1569-d.

———.‘TheArtandScienceofTraditionalMedicinePart2:MultidisciplinaryApproachesforStudyingTraditionalMedicine’.Science347,no.6219(16January2015):337–337.https://doi.org/10.1126/science.347.6219.337-c.

Sellman,Derek.‘PracticalWisdominHealthandSocialCare:TeachingforProfessionalPhronesis’.Accessed14October2017.https://journals-scholarsportal-info.proxy.bib.uottawa.ca/details/14736853/v08i0002/84_pwihasctfpp.xml&sub=all.

Sherwin,Susan.‘Foundations,Frameworks,Lenses:TheRoleofTheoriesinBioethics’.Bioethics13,no.3–4(1July1999):198–205.https://doi.org/10.1111/1467-8519.00147.

Sidgwick,Henry.TheMethodsofEthics.6thed.London;NewYork:MacMillanandCo.Limited;TheMacmillanCompany,1901.http://tinyurl.galegroup.com/tinyurl/4YWos4.

‘Single-PayerSystemDefinition’.healthinsurance.org,23September2017.https://www.healthinsurance.org/glossary/single-payer-system/.

Spence,William,andNaLi.‘AnExplorationofTraditionalChineseMedicinePractitioners’PerceptionsofEvidenceBasedMedicine’.ComplementaryTherapiesinClinicalPractice19,no.2(1May2013):63–68.https://doi.org/10.1016/j.ctcp.2013.02.003.

‘StandardsofPractice·CTCMPAOWebsite’.Accessed31January2018.https://www.ctcmpao.on.ca/regulation/standards-of-practice/.

‘StandardsofPractice·CTCMPAOWebsite’.Accessed5October2017.https://www.ctcmpao.on.ca/regulation/standards-of-practice/.

Stone,Richard.‘LiftingtheVeilonTraditionalChineseMedicine’.Science319,no.5864(8February2008):709–10.https://doi.org/10.1126/science.319.5864.709.

108

Sun,L.,S.Zhu,Y.Chen,andCWang.‘PCV34-TheCost-EffectivenessofFourChinesePatentMedicineintheTreatmentofAnginaPectorisinChina’.ValueinHealth17,no.7(1November2014):A761.https://doi.org/10.1016/j.jval.2014.08.261.

Tang,Jin-Ling,Si-YanZhan,andEdzardErnst.‘ReviewofRandomisedControlledTrialsofTraditionalChineseMedicine’.BMJ319,no.7203(17July1999):160–61.https://doi.org/10.1136/bmj.319.7203.160.

Taylor,Kim.ChineseMedicineinEarlyCommunistChina,1945-63:AMedicineofRevolution.NeedhamResearchInstituteStudies.London ;NewYork:RoutledgeCurzon,2005.

‘TCMRegulationinCanada|C.M.A.A.C.–PromotionTCMandAcupuncture’.Accessed28September2017.http://www.cmaac.ca/public/tcm-regulation-in-canada.

‘TheCanadaHealthAct’.Accessed31January2018.https://lop.parl.ca/Content/LOP/ResearchPublications/tips/tip74-e.htm.

TheRoyalCollegeofPhysiciansandSurgeonsofCanada,andLisaLittleConsulting.‘DefiningSocietalHealthNeedsRoyalCollegeDefinitionandGuide’,April2012.royalcollege.ca.

‘TraditionalChineseMedicinePractitioner’.Accessed6February2018.http://healthsciences.humber.ca/programs/traditional-chinese-medicine-practitioner.html.

Unschuld,PaulU.MedicalEthicsinImperialChina:AStudyinHistoricalAnthropology.ComparativeStudiesofHealthSystemsandMedicalCare ;Berkeley:UniversityofCaliforniaPress,1979.

‘WHO|WHOTraditionalMedicineStrategy:2014-2023’.WHO.Accessed3May2018.http://www.who.int/medicines/publications/traditional/trm_strategy14_23/en/.

Wilkinson,JohnR,andScottAMurray.‘AssessmentinPrimaryCare:PracticalIssuesandPossibleApproaches’.BMJ :BritishMedicalJournal316,no.7143(16May1998):1524–28.

Wright,John,RhysWilliams,andJohnRWilkinson.‘DevelopmentandImportanceofHealthNeedsAssessment’.BMJ :BritishMedicalJournal316,no.7140(25April1998):1310–13.

Wu,Changguo.BasicTheoryofTraditionalChineseMedicine.EditedbyWuGuochang.Shanghai:ShanghaiCollegeofTraditionalChineseMedicinePress,China,2002.

Xue,Pei,TianyuZhan,GuoyanYang,GiuseppinaMariagraziaFarella,NicolaRobinson,AngelaWeihongYang,andJianpingLiu.‘ComparisonofChineseMedicineHigherEducationProgramsinChinaandFiveWesternCountries’.JournalofTraditionalChineseMedicalSciences2,no.4(1October2015):227–34.https://doi.org/10.1016/j.jtcms.2016.01.010.

Yuan,Wei.‘AcupunctureComestoCanada:TheStruggleforProfessionalRecognition,1970-1996.’Thesis,UniversityofOttawa(Canada),2001.http://dx.doi.org/10.20381/ruor-14751.