Intended for healthcare professionals

Rapid response to:


The safety of acupuncture

BMJ 2001; 323 doi: (Published 01 September 2001) Cite this as: BMJ 2001;323:467

Rapid Response:

Attributable Risk a better concept than Adverse Effect

Elsewhere I've written how problematic it is to define let alone
quantify adverse events associated with acupuncture.
I think this is echoed to some degree in this article by Vincent. He
like so many others have left out an issue I think needs highlighting: if
one understands the principles behind traditional forms of acupuncture,
the notion of an adverse event becomes problematic. As we attempt to
utilize the same terminology and methodology that has been applied to
pharmaceutical and specific surgical interventions -- with acupuncture
practiced in a traditional manner -- we are going to encounter problems.

In Western thought, if the result is anything but its intended result,
then it is an adverse event or side effect. This is the result of linear
reasoning. Linear reasoning does not translate well to acupuncture based
on Oriental contextual models. For example, a patient receives acupuncture
for neck pain with the only immediate result a sense of deep relaxation.
Our Western paradigm would equate the relaxation with an adverse event
(Relaxation has been actually termed an adverse event in some reviews)
However, from a contextual Oriental Medical approach, if the patient
learns to relax, then over time, his neck pain may improve. So that
relaxation would not be defined as an adverse event, but a salutary effect
of the acupuncture. This may appear as mere semantics. Clinical
implications could however, be significant. Patients may well halt
treatment or be unnecessarily concerned if they develop symptoms other
than those anticipated especially if we convey to patients that all
unexpected/unwanted events are adverse. We can still help patients
evaluate the risks associated with acupuncture by outlining the estimated
attributable risk of such events. In my opinion, this meets the ethical
challenge of providing informed consent. However, this is pragmatically
moot; standards of practice dictate that unless the attributable risk of a
serious event to a procedure is relatively high (greater than 1 in 500),
one is not obliged to discuss it with the patient. For example, we do not
require informed consents for drawing blood despite the possibility of
fainting, bruising, and even infection except, perhaps, in those cases
where the risk is high such as in a post-mastectomy patient. I believe
that given the low incidence of serious adverse events associated with
acupuncture, a formal informed consent is not indicated.

I think if we continue to use the same terminology and methodology to
evaluate acupuncture as we do pharmaceutical agents, we neither understand
classically applied acupuncture or the limits of our standard Western

Also I want to comment briefly about some colleagues questioning the
benefits of acupuncture. It's obvious the benefits of acupuncture are
significant, now to what degree they have to do with specific needling
techniques or some enhancement of the placebo effect this all needs to be
worked out. I just think it is ludricous for intelligent and/or informed
individuals to deny the possible significant benefits to patients who are
cared for by a qualified acupuncturist. Since it is a surgical procedure
I also vote to involve physicians in it's delivery.

Competing interests: No competing interests

16 September 2001
James K Rotchford
President of Medical Acupuncture Research Foundation
Port Townsend, WA USA