The Ethics of Alternative Medicine

1. The Ethics of Alternative Medicine Acupuncture Dr . NUSHROTUL LAILIYYA, Sp.S, Sp.AK Neurologist & Acupuncturist Department of Neurology-Hasan Sadikin Hospital-Medical Faculty-Padjadjaran University

2. Mr. Chen, a 40 y.o. patient originally from China, had lumbar problems for one year. The condition includes dull pain in his leg and the inability to sit for long periods. X-ray examination reveals a prolapsed lumbar disc. He has been treated with conventional pain medication with minimal effect. His physician, Dr Robert O., recommends back surgery, but Mr Chen reluctant to take this opinion. Instead, he asks the doctor to refer him to an acupuncturist because his insurance coverage requires physicians’s approval for alternative therapy. But Dr Olsen is skeptical about any kind of alternative therapy. He refuses to order the acupuncture. Did the physician act ethycally?

3. AkupunkturmerupakankomponenpentingdariTradisional Chinese Medicine SAAT INI AKUPUNKTUR MEDIK ??

5. SEJARAH

7. Penyebaran akupunktur DokterBelanda : - Ten Rhiyne (1683) - E Kampfer (1712) Perancis : L Berlioz (1816) Belgia : Y Koyen (1849) Swiss : - Y Cramer (1857) - Soulie de Morant (1929) : terjemahkanPelajaranakupunkturdanmoksibusi Elektro-akupunkto-kauterisator Elektro-detektor

8. Penyebaran akupunktur Amerika : 1826 Meksiko : 1940 Argentina : 1950 Brasil : 1950 Korea Utara : Prof Kim Bong Han → meridian dan titikakupunktur • 1949 : penelitianklinis • 1958 : akupunkturanestesia • 1963 : Indonesia – RSCM : timriset ilmupengobatantimur – UPF akupunktur • 1996/97 : DitJenBinKesMas (akupressuredan pengobatantradisional)

9. akupunktur Diintegrasikan ke dalam sistim pelayanan formal - Resolution WHO 44.34 - Permenkes RI NO. 1186/Menkes/ Per/XI/1996

10. Dokumen - dokumen WHO ttg Akupunktur Standard acupuncture nomenclature part 1 Standard acupuncture nomenclature part 2 Guidelines for clinical research on acupuncture Guidelines on basic training and Safety in acupuncture

11. DEFINISI Bioethics is the philosophical study of the ethical controversies brought about by advances in biology and medicine. Bioethicists are concerned with the ethical questions that arise in the relationships among life sciences, biotechnology, medicine, politics, law, philosophy, and theology.

12. PURPOSE AND SCOPE The field of bioethics has addressed a broad swath of human inquiry, ranging from debates over the boundaries of life (e.g. abortion, euthanasia) to the allocation of scarce health care resources (e.g. organ donation, health care rationing) to the right to turn down medical care for religious or cultural reasons.

13. PRINCIPLES The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research was initially established in 1974 to identify the basic ethical principles that should underlie the conduct of biomedical and behavioral research involving human subjects. However, the fundamental principles announced in the Belmont Report (1979)--namely, autonomy, beneficence and justice--have influenced the thinking of bioethicists across a wide range of issues. Others have added non-maleficence, human dignity and the sanctity of life to this list of cardinal values.

14. AKUPUNKTUR acupunkture PASIEN TINDAKAN STERILITAS JARUM INFORMED CONSENT KASUS/ISSUES SIAPA, DLL BIOETHIC

15. Babies, acupuncture and the secret to a good night's sleep

19. Safety in Acupuncture Amankah tindakan Akupunktur ? Ditangan yang kompeten akupunktur merupakan suatu tindakan yang relatif aman dengan beberapa kontra indikasi dan komplikasi. Perhatikan transmisi infeksi yang merupakan faktor resiko tindakan akupunktur

20. Resiko Tindakan akupunktur : - Transmisi infeksi (hepatitis, HIV) - Jarum patah, bengkok - Reaksi yang tdk diharapkan- Nyeri dan rasa tidak nyaman - terlukanya organ dalam

21. Pencegahan Infeksi : • Lingkungan kerja yang bersih • Tangan pengobat yang bersih • Persiapan bagian tubuh yang akan di akupunktur • Jarum , alat dan kotak penyimpanan harus steril • Tehnik aseptis • Penanganan yang cermat untuk jarum bekas dan kapas bekas

22. Kontra Indikasi • Kehamilan • Kedaruratan medik • Kasus pembedahan • Tumor ganas • Gangguan pembekuan darah dan sedang dalam pengobatan antikuagulantia

23. CONTROVERSIES ISSUES OF ACUPUNCTURE YIN-YANG

25. Malam Barat/utara Dingin Air Bulan Perut Permukaandalam Darah Kronis Merasadingin Depresi Lemah Sakit Siang Timur/selatan Panas Api Matahari Punggung Permukaanluar Energi/chi Akut Merasapanas Senang Kuat Sehat Yin-yang

26. ACUPUNCTURE YINYANG HOMEOSTASIS

28. Aktivitas energi di meridian • Meridian I (Paru-paru) • Meridian II (UB) • Meridian III (Lambung) • Merridian IV (Limpa-pankreas) • Meridian V (Jantung) • Meridian VI (UK) • Meridian VII (KK) • Meridan VIII (Ginjal) • Meridian IX(Sampul jantung) • Meridian X (Tri pemanas) • Meridian XI (K.Empedu) • Meridan XII (Hati) • Jam 3.00 – 5.00 • Jam 5.00 – 7.00 • Jam 7.00 – 9.00 • Jam 9.00 – 11.00 • Jam 11.00 – 13.00 • Jam 13.00 – 15.00 • Jam 15.00 – 17.00 • Jam 17.00 – 19.00 • Jam 19.00 – 21.00 • Jam 21.00 – 23.00 • Jam 23.00 – 1.00 • Jam 1.00 – 3.00

32. Medical ethics is the study of moral values and judgments as they apply to medicine. As a scholarly discipline, medical ethics encompasses its practical application in clinical settings as well as work on its history, philosophy, theology, and sociology.

33. What Can Acupuncture Treat?

34. While acupuncture is often known to its effectiveness in pain control, The World Heatlh Organization (WHO) recognizes the use of acupuncture in the treatment of a wider range of medical problems, including: Muscular and Skeletal Disorders: arthritis, tennis elbow, frozen shoulder, neck pain, TMJ, sciatica, low back pain, fibromyalgia, carpal tunnel syndrome, knee pain.

35. Acupuncture is most commonly used for pain, such as back, neck and spine pain, herniated discs, nerve irritation, sciatica, headache, facial pain, jaw pain (TMJ), menstrual pain, arthritis, sprains, muscle strain, repetitive strain injuries, tendonitis, sports or auto injury. Acupuncture and Chinese medicine are also very effective for viral infections such as colds/flu’s and hepatitis.

36. Are there ailments acupuncture isn't effective to treat? WHAT IS ACUPUNCTURE ? Cancer is not treatable by acupuncture, although it is effective in resolving the nausea associated with chemotherapy treatment. AIDS also does not respond to acupuncture, although acupuncture can be used to boost the immune system, it cannot reverse the effects of HIV.

37. Safety in Acupuncture AmankahtindakanAkupunktur ? Ditangan yang kompetenakupunktur merupakansuatutindakan yang relatifaman denganbeberapakontraindikasidan komplikasi. Perhatikantransmisiinfeksi yang merupakan faktorresikotindakanakupunktur

38. Medical ethics tends to be understood narrowly as an applied professional ethics, whereas bioethics appears to have worked more expansive concerns, touching upon the philosophy of science and issues of biotechnology. Still, the two fields often overlap and the distinction is more a matter of style than professional consensus. Medical ethics shares many principles with other branches of healthcare ethics, such as nursing ethics.

39. PenelitianAkupunktur : * PenelitianAkupunkturDasar - TitikAkupunktur - Meridian - Mekanismekerja * PenelitianAkupunkturklinis terkaitdengansetiapsistemtubuh

40. Berbagaipenelitiantelahmembuktikan keberadaantitikakupunktur, ygberbedadengansembaranglokasibukantitik akupunkturdalamhal : • Strukturanatomidanhistologi • Fenomenakhas • Efekrangsang

41. StrukturAnatomidanHistologiTitikAkupunktur • Kellner (1965) melalukan 12.000 mikroseksipada 11 titik akupunktur : tidakditemukansesuatu yang unik, kecuali akhiransarafpadalokasititikakupunkturlebihpadat Padalokasiakupunktur, satureseptoruntuk 2,80 mm2 dan lokasibukantitikakupunktur 12,83 mm2. • Gunn et al (1976) meneliti 70 buahtitikakupunktur : 47 terletakpadatitikmotorik (tipe I) 11 terletakdigarissagital, pertemuansarafsuperfisialkedua belahtubuh (tipe II) 12 terletakpadapleksussarafatausarafkutaneussuperfisial (tipe III) 1977 : titikakupunkturterletakdiatasotot –tendon (tipe IV) kesimpulan : titikakupunkturterletakdi area kayasaraf superfisial.

42. Fan et al (1990) : dengan mikroskop elektron pada pembesaran 20.000 kali mendapatkan celah antar sel (gap junction) di epidermis pada lokasi titik akupunktur dua kali lebih banyak dibanding lokasi bukan titik akupt. • Croley & Carlson (1991) mendapatkan papila dermis pada lokasi titik Akupunktur dua kali lebih banyak • Kawakita (1993) : reseptor rangsang akupunktur, mekanis maupun termis, adalah sama yaitu reseptor polimodal, yg merupakan akhiran bebas yang teranyam dari saraf sensorik tak bermielin (serabut C), saraf sensorik kecil bermielin (serabut A-delta) dan saraf sensorik besar bermielin (serabut A-beta) reseptor polimodal : sensitisasi memunculkan nyeri tekan; eksitasi menimbulkan : rasa jarum, reaksi inflamasi lokal, aktivasi sistem analgetik (dimediasi opioid atau mediator kimiawi lainnya), serta aktivasi sistem regulatorik.

43. Ethical Considerations for Acupuncture and Chinese Herbal Medicine Clinical Trials: A Cross-cultural Perspective* Christopher Zaslawski College of Traditional Chinese Medicine, Department of Medical and Molecular Biosciences, Faculty of Science, University of Technology, Sydney, Australia Many ethical concerns revolve around the four basic principlesof research: merit and integrity, respect for human beings,weighting of risk–benefit and justice. These principlesform the basis for any discussion concerning human researchethics and are applicable to all areas of research includingacupuncture and Chinese herbal medicine. World Health Organisationdocument, Guidelines for Clinical Research on Acupuncture, statesthat ‘consideration should be given to the different valuesystems that are involved ….. For reprints and all correspondence: Christopher Zaslawski, College of Traditional Chinese Medicine, Department of Medical and Molecular Biosciences, Faculty of Science, University of Technology, Sydney 2007, Australia. Tel: +61-2-9514-7856; Fax: +61-2-9514-7866; E-mail: chris.zaslawski@uts.edu.au

44. The Journal of Alternative and Complementary Medicine Methodological and Ethical Issues in Clinical Trials of Acupuncture Richard Hammerschlag, Ph.D. Yo San University of Traditional Chinese Medicine, Santa Monica, California. In this review, controlled clinical trials of acupuncture are placed into five categories on the basis of the treatment with which acupuncture is compared. Methodological and ethical issues relevant to each category are discussed. Wait list (or no treatment) controls, which are ethically acceptable for stable, chronic conditions, assess the efficacy of acupuncture relative to the natural history of the condition but do not control for nonspecific treatment effects. Placebo controls, defined here as noninvasive procedures such as inactive transcutaneous electrical nerve stimulation (TENS) or mock needling, assess whether acupuncture has an effect beyond that of the therapeutic milieu. Sham controls, defined as invasive but inappropriate procedures such as shallow needling at nonacupoint sites, assess whether acupuncture efficacy depends on the style and location of needling…. To cite this article:Richard Hammerschlag. The Journal of Alternative and Complementary Medicine. Summer 1998, 4(2): 159-171. doi:10.1089/acm.1998.4.159. Published in Volume: 4 Issue 2: September 10, 2007

45. The largest "randomized" acupuncture study ever done Category: Alternative medicine • Clinical trials • Medicine For the current study, published in the journal Cephalalgia, German researchers followed more than 15,000 adults with chronic headaches; all had been suffering from either migraine or tension-type headaches at least twice a month for 1 year or more.

47. RESULT At 3 months, the number of days with headache decreased from 8.4 ± 7.2 (estimated mean ±s.e.) to 4.7 ± 5.6 in the acupuncture group and from 8.1 ± 6.8 to 7.5 ± 6.3 in the control group (P < 0.001). Similarly, intensity of pain and quality of life improvements were more pronounced in the acupuncture vs. control group (P < 0.001). Treatment success was maintained through 6 months.

48. ACUPUNCTURE - ADENOSINE - AMP - ADP - ATP

49. Visualisasi Meridian MenggunakanTeknikPemeriksaanKedokteranNuklir Radiofarmaka: Tc-99m pertechnetate Biodistribusi: Kel. ludah, kel. tiroid, lambung, GUT.

50. PC1 PC3 PC6 SJ10 (?) R L SJ5 SJ10 (?) R L SJ5 PC3 SJ10 (?) R L SJ4 Statik 5 menit, aliran ke atas / ke PC1 (Tianquan) (?) SJ5 (Waiguan), statik 10 & 20 mnt Kiri: Titik Akup(Deqi), Kanan: intradermal Kiri: aliran ke atas ke SJ10(Tianjing?)