Changing the name won’t save acupuncture. A counter-response to FISA

FISA, the Italian Federation of Acupuncture Societies, has responded to an article I wrote on 14 April in "Il Foglio", which focused on studies linking the use of complementary medicine in oncology to a lower standard of effective treatment and poorer survival rates.

I came across this by chance, and therefore rather belatedly, as nobody had brought it to my attention, but I must say that the response is interesting because it highlights a recurring tactic in the promotion of pseudoscience within the medical field: a practice originating within a pre-scientific system is taken, placed within an institutional setting, entrusted to professionals with university degrees and registered with the professional body, and then this framework is used to obscure the main issue, whilst ostensibly modernising itself by drawing on operational mechanisms based on the latest research. In reality, however, the practice retains part of its original symbolic framework, and that framework enters the therapeutic relationship with a competitive advantage: it appears humane, ancient, gentle and respectful of the body, whilst effective medicine often appears harsh, toxic, exhausting and bureaucratic. This is where pseudoscience comes in: not because there is a lack of recent scientific literature on the possible benefits of acupuncture and, above all, on its possible mechanisms of action – and we shall address the robustness of this literature separately – but because, in reality, this evidence is used almost defensively in the face of the scientific community, whilst patients continue to be fed all manner of tall tales; and, at the same time, in the name of integration, the practice is expanding into areas that lack any validation whatsoever, only to then deny any correlation with effects such as patients abandoning their treatments and increased mortality in oncology – effects that the literature does indeed prove.

But let’s get to the point. The FISA response works like this. My article discussed clinical outcomes documented in the literature: refusal or incompleteness of treatments, delays, survival. The response shifts the focus to the definition of Italian acupuncture: medical practice, training, public clinics, symptomatic use, support for adherence. It is a diversion from the subject at hand. The real and useful question to answer concerns what happens once the practice is incorporated into the cancer care pathway: does the patient complete effective treatments more successfully, complete them just as well, or miss out on parts of them? The reply responds by describing what Italian acupuncture claims to be. In medicine, however, a practice’s self-description carries no weight; when faced with data demonstrating a correlation with lower adherence and higher mortality, the response must be based on further data, not on hopes and wishes.

This passage needs to be singled out because it is at the heart of the matter. FISA advocates integration, and ‘integration’ has become a term that is highly valued and cherished by patients, as it evokes collaboration and prudence, and is associated with other terms (over which, incidentally, there seems to be a desire to claim exclusivity, in contrast to ‘traditional’ medicine) such as ‘listening’ and ‘quality of life’. The concept of integration allows it to be distinguished from the cruder forms of alternative medicine – those which, for example in oncology, claim to replace surgery, radiotherapy, chemotherapy or endocrine therapy, thereby leading patients to their deaths.

This distinction certainly has its conceptual value, but it can become a way of sidestepping the empirical problem. We are all well aware of how a cancer patient may embark on the correct, often gruelling, course of treatment, only to lose sight of crucial aspects along the way, accepting one therapy whilst rejecting another. In other words, the patient may divide their trust between effective medicine and palliative care in a clinically disadvantageous way, without having any accurate perception of the risks – and, in any case, obviously guided by very human and entirely understandable biases. The harm, when it emerges, can result from partial, gradual and barely noticeable decisions, without the caricatured scene of the healer ordering the patient to leave the hospital – and it is a harm that the articles I cited in my original piece document thoroughly.

FISA’s response also employs a second diversion: it cites guidelines on acupuncture for certain forms of cancer-related pain. This argument has a clear scope. Pain is a symptom; survival is an outcome. Pain management, when documented, may justify symptomatic intervention within defined limits and is welcome. However, this does not provide evidence that acupuncture improves adherence to critical cancer treatments. To support this claim, data are needed on treatment completion, interruptions, delays, omissions, follow-up, and comparisons with comparable patients. If FISA wishes to defend integrated oncology as a means of safeguarding the cancer care pathway, it must demonstrate that the pathway is actually being safeguarded. The intention to support adherence remains merely a statement until it is measured – I am therefore certain that FISA’s doctors will provide data to support the fact that acupuncture is not among the complementary practices that influence survival and adherence in oncology, alongside all those grouped together in the literature that I cited previously.

The third point concerns a classic rhetorical device. FISA insists that in Italy, acupuncture is practised by doctors. This factor may be important for procedural safety and for coordination with oncologists. It reduces certain practical risks, particularly compared with practices carried out outside the healthcare system. However, it can also become an inappropriate smokescreen. A professional’s qualification does not automatically transform a pre-scientific conceptual framework into a scientific one. A doctor may use a procedure with caution whilst simultaneously allowing words, images and categories to slip through that alter the patient’s perception. In oncology, this distinction carries significant weight. The tradition of acupuncture brings with it meridians, Qi, deficiencies, excesses, energies, rebalancing and the organs of Chinese medicine – and FISA is well aware of this. When this language is criticised by FISA, it is dismissed as metaphor, but this is a weak solution designed precisely to avoid issuing overly strong condemnations of pseudoscience. A medical metaphor serves to make a real process more understandable; a metaphor without a verifiable biomedical referent produces a second language of disease, and above all reinforces pre-scientific and vitalistic concepts which are precisely the ‘cognitive toxins’ I often speak of. If a traditional formula does not correspond to an anatomical organ, a lesion, a biomarker, a validated pathophysiological pathway or a diagnosis that can be formulated using verifiable criteria, it must be condemned in no uncertain terms, since it introduces a representation of illness and the body that is alternative to, and cannot be integrated with, medicine, and therefore can lead – and does lead – patients to rely on imaginary realities. The issue concerns the transfer of credibility: the doctor lends a portion of their own authority to the traditional category.

This is the point at which pseudoscience becomes most effective in infiltrating our healthcare system, with the legal backing of recognition as a medical practice. Outside mainstream medicine, it can be recognised more easily; within a surgery, using the language of ‘complementary medicine’ and under the supervision of a doctor, it becomes more difficult to distinguish from the rest. Pre-scientific terms lose their folkloric air and gain respectability. In fact, unless they have specific training, patients cannot distinguish between a symptomatic procedure, the use of a placebo and an alternative explanatory framework. This confusion, which does not require an explicit lie, arises from proximity and the lack of a clear demarcation between what is proven and what is justified as a ‘metaphor’.

FISA could have responded to my letter much more forcefully, and I have some hope that it will do so. As this concerns acupuncture, and not homeopathy, anthroposophic medicine or other practices whose descriptions are entirely divorced from reality, it could have demonstrated, with data to hand: in our integrated cancer care pathways, patients undergo radiotherapy, endocrine therapy, chemotherapy and surgery at least as often as those in the control groups; we have data on delays, interruptions, refusals and follow-up; we have verified the language used in consultations; we have ruled out traditional explanations that might confuse patients about the nature of the disease; we have measured outcomes. A response of this kind would have shifted the discussion onto the right track. Instead, the published reply opts for the ground that best lends credence to all forms of pseudoscience: professional identity, references to pain, the intention to provide support, and an abstract distinction between ‘integration’ and ‘alternative’ approaches.

The result is a revealing text. FISA does not refute the issue raised by the studies; rather, it reframes it in a way that makes acupuncture appear more presentable. The reader is invited to consider the medical context, whilst the issue at hand concerns the overall effect on the course of treatment.

Oncology is not the right place for well-meaning semantic experiments, bearing in mind that the right communication can easily help a patient endure months of gruelling treatment because they have understood that this effort alters their prognosis, but they may also abandon part of their treatment journey because a different way of speaking has made an alternative choice more acceptable to them. For this reason, every practice incorporated into the cancer care pathway must also be assessed for the effect it has on the patient’s mental hierarchy of care. A system of pre-scientific terminology, presented at the patient’s bedside with the authority of a doctor, requires far more robust evidence of its harmlessness – evidence capable, at the very least, of countering the data published to date and which I have cited.

This is, of course, a technical debate, which is not intended to be conducted in "Il Foglio"; I have attempted to address it with greater accuracy and rigour elsewhere, and here I shall merely point out that, in schools which issue FISA certificates, subjects such as "QI, XUE, JING and JINYE syndromes: pathophysiology, clinical presentation and treatment – 8 DIAGNOSTIC RULES’, or the ‘ZANG FU SYNDROMES: pathophysiology, clinical presentation and treatment’, or the ineffective and pseudoscientific practice of moxibustion; so this is far from mere metaphor.

To conclude, I would just like to make one final point: cancer patients have the right to relief, but above all they have the right to a care pathway in which no word, no metaphor, no practice and no professional body deprives them of the treatment that can truly save their lives – as the data show happens all too often.