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Which Medicine? Whose Standard? Critical Reflections on Medical Integration in China Author(s): Ruiping Fan and Ian Holliday Reviewed work(s): Source: Journal of Medical Ethics, Vol. 33, No. 8 (Aug., 2007), pp. 454-461 Published by: BMJ Publishing Group Stable URL: . Accessed: 24/12/2012 07:36
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GENERAL ETHICS Which medicine? Whose standard? medical integration in China

Ruiping Fan, IanHolliday
JMed Ethics 2007;33:454-461. doi: 10.1136/?me.2006.017483


reflections on

There is a prevailing conviction that if traditional medicine (TRM)or complementary and alternative medicine (CAM) are integrated into healthcare systems, modern scientific medicine (MSM) should retain its principal status. This paper contends that this position ismisguided inmedical contexts where TRM is established and remains vibrant. By reflecting on the Chinese policy on three entrenched forms of TRM (Tibetan, Mongolian and Uighur medicines) inwestern regions of China, the paper challenges the ideology of science that lies behind the demand that all traditional forms of medicine be evaluated and reformed according toMSM standards. Tibetan medicine is used as a case study to indicate the falsity of a major premise of the scientific ideology. The conclusion is that the proper integrative system for TRM and MSM is a dual standard based system in which both TRM and MSM are free to operate according to their own medical standards.

available from hospitals and clinics. pies are widely At the other TRM may have no more than extreme, a even limited it is indeed presence, though in "all areas": clinical research, education, In such a case, and pharmacy. practice incorpora tion of TRM into a so-called is "integrative system" no more than is clearly token, which problematic. present The question fundamental. standard popularly by which of "whose standard" is even more a medical embodies Every medicine in the form of a set of professionally and rules and mechanisms norms, approved specific diagnostic, therapeutic and

are pharmaceutical practices (including products) in healthcare validated for use settings. Evidently, there medical set up MSM, policy adopted an are as many standards different as medical system, therefore and there incommensurable are various In order as for TRM to formulate that and to and a

incommensurable integrative

traditions. such needs standard and there MSM

government regarding for selecting, practice. TRM

the medical

is to be

integrative Traditional tary and medicine alternative and (TRM) medicine attention. is that into if possibilities: dual based, are the of MSM own (whereby

operating In principle, standard based, based

regulating are several standard TRM to and their based of mixed

complemen (CAM) However, forms


(whereby according standard out

operate standards), a new

attracting prevailing medicine modern

growing conviction

independently new and standard


is framed

are integrated scientific medicine status. In this

healthcare should

its principal this position where this has TRM article,

(MSM) article, we and remains

systems, retain that

possible This

and MSM








TRM and MSM?

on these issues paper explores by reflecting case of China. In particular, it focuses special on three formally autonomous in the north regions and west: Inner Mongolia, In Tibet and Xinjiang. each is the major group region, indigenous the dominant, substantial but at the same time Chinese coexists and with smaller numbers of Han

is misguided is established attention

in medical

contexts vibrant.1 to TRM of as China. most and who argue In it

is not the

directed Han

among developed people This form of TRM what constitutes roughly in the West as "Chinese medicine"; identify been take that system explore icine explored the dominance elsewhere.12 of MSM Against for granted, appropriate it is first those we


in order

an to develop for MSM and TRM two fundamental be be

integrative to necessary Which med medical


should should

emphasised? adopted?

questions. Whose

and alternative CAM, complementary scientific medicine; TRM, medicine; MSM, modern traditional medicine; WHO, World Health Organization 'As will be made clear, what we are focusing on is long embedded forms of indigenous genuinely and Mongolian medicine. Tibetan, Uighur,

See end of article authors' affiliations


standard These seriously

fundamental addressed.

questions The dominant


not position

been is

and standing TRM, such as on

to: Correspondence Professor Ruiping Fan, of Public and Department Social Administration, City University of Hong Kong, Kowloon, Hong Kong;

documents an

in World

the WHO TM/CAM into

claims states is that

"[i]n an

Thisdoes not include formsof CAM thathave been grafted

to healthcare underpinnings practised. We

promote system.

of TRM within


integrative and nised provision".3 incorporated" open-ended

system, incorporated However,

recog officially all areas of healthcare recognised and an is


Received 24 May 2006 Revised 9 August 2006

Accepted 16 August 2006

is a vague spectrum. considerable in TRM

requirement, implying one At there extreme, support and practices, state for research TRM

and often have few or no systems, are now inwhich in the society being they the scepticism with which fully understand 31 are often such forms of medicine greeted by physicians,30 and we have no interest in saying how they might be into established healthcare integrated systems.32 The three are forms of TRM under discussion founded on the actually concept of "knowing practice" analysed by Farquhar33 and the forms of transmission examined is by Hsu.34 Our concern how these forms of TRM should be brought within contemporary policy frameworks.

presumably and education


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Critical numbers indigenous the local medicine remains For

reflections of other group tradition is widely strong.

on medical


in China In each TRM.


indigenous peoples. has an entrenched is Mongolian practiced, these and

medicine. in Xinjiang, form

the major region, In Inner Mongolia, In Tibet, Tibetan Uighur a medicine


Momentous and from the Western consequent the mid-19th some central the meeting with engagement of MSM and Chinese TRM civilisation, in China, dates the history of engage Inner Mongolia, Tibet and common, espe essentially in 1949. Republic People's history region toward the comprises of the country. TRM and MSM on the more insistence to

core our modern of First, questions. of the three TRM forms invite and current presence experience in medical of a significant issue careful epistemology: study we the effectiveness of TRM and how might compare properly in these This is far more three MSM? interesting question in Chinese heartland because the than the Han regions marginal imposed standard. examine status "scientific" Moreover, the dominant of indigenous evaluation it is TRM forms results with challenging the only from the MSM to appropriate re an in accordance intellectually that

many consideration



good the



ment Xinjiang, cially

exhibited the after

century. Although in differences themes of were the

creation modern

Throughout gradual At the same

China, domination time, has

medical in every attitude the core vibrant most

of MSM the official from as

integration as TRM recent

changed the key standard of MSM favouring TRM in rural the areas, than

of medical the

19th-century excellence standard.11 in all

Nevertheless, Particularly TRM remains turn cities, cohabit public MSM profile relevant so-called quantity healthcare to TRM however, and the investment facilities. than MSM. areas:

remains where


regions. live,


standards evidence

as to support standards?

of TRM and MSM

Is claim? there Is there solid any an this

is to take MSM
epistemological reason convincing

folk medicine, MSM

indigenous and most people for healthcare. and based, been



rather where

instinctively In the major Han the Chinese bulk of

MSM of the

the medical
indigenous a carries of to be

legitimacy of TRM must

Finally, ways significant of as TRM life remains in these regions,

be determined
essential element


top in medical In

indigenous people are officials regional institutions TRM in all and has three


issues and of the

practical people

choices life are


implication. in living their

these exploring If the wishes preferred ways in which be

consequence, is the case This clinical

into poured a much smaller and in all The in both


educational, system" and TRM

respective created. The provision section first main

medical systems integrative respected, TRM find their proper systems places section of the article Tibet of the fusing


"integrative and quality, provision contrast

is dominated

pharmaceutical. by MSM

in Inner Mongolia, the danger explains section subsequent lays out behind the demand that all evaluated following comparing "whose Tibetan and reformed

medical surveys briefly next and Xinjiang. The TRM into MSM. science that The lies be

a striking is TRM, whereas Context In made 2000,

is only marginally in the present As a result, institutions. leading medical exists in the three the folk medicine regions: the official institutional medicine is MSM. of

of ideology traditional forms

Inner of

of medicine

to MSM standards. The according on improving TRM measures focus and cases in both the question effectiveness, posing two The sections second of these standard?" takes two sections medicine as of a case the study scientific depends to indicate the of an falsity the effective to aetiology, concludes is a dual the

up numbered

Mongolia Han both million,

had Chinese making the to

a population of and Mongolians.4 century, dominate the been Tibetan up 20th about 17%




Mongolians of the total Western

regional medicine Mongolian medicine, in Buddhist

population.5 gradually medicine Indian

During came has


medicines, it has

always and

important premise ness of medical general and


pathogenesis that the proper

particular and therapy integrative to their

explanatory in MSM. found system own

that ideology, on it conforming accounts of The article

region. Although influenced by Chinese as practised medicine tradition.6 with the 2.41 million,4 of

In 2000, million

temples, Tibet had


long existed a population of about constituting culture extreme

as a separate 2.62 92%

for TRM

and MSM

standard based form in which

operate according

both TRM and MSM

medical standards.

are free to

Tibetan population.7 Although Buddhist the context, purely much medical particular, Buddhism: of

is generally isolation

regional found in a Tibet for and In of


means its history that its religion, philosophy tradition have had distinctive elements.8 always are a unique characterised branch they by Tibetan Tantric Buddhism.9 Xinjiang had a population medicine of 19.25

"To summarise China. Phase in 1911) was

indicatedifferent official attitudes towardMSM and TRM integration in

I (from the mid-19th century to the collapse of imperial China a TRM standard based was medicine integration. Chinese of all taken to hold the correct and principles foundations, purposes treatments were only admitted as useful therapeutic and MSM medicines, to the opposite II (1911-1949) means.35 Phase moved The position. offered "unconditional Nationalist government support" toMSM, whereas or the "collected TRM was taken to be a "feudal" of practice garbage that should be prohibited from practice.36 Phase III several thousand years" was marked a Maoist to create a "new (1950s-1980s) campaign by a combination of the best aspects of both Chinese and medicine" through a new to produce Western It attempted standard based medicine. TRM and MSM while from mixed standards, integration being "fully or elitist".37 Phase to IV (from the 1980s scientific without foreign being a "three roads" characterised now) is apparently policy. The drive to by in the early 1980s. create a new medicine was substantially downgraded of TRM and MSM have all TRM forms, MSM, and a conjunction Officially, to exist. However, the three roads are not since been granted the freedom accorded Rather, MSM has the upper hand, and TRM is importance. equal using the MSM standard.36 required to prove its effective properties integration has thus taken an MSM standard phase, TRM and MSM form. In this based

this complex


four phases

can be distinguished

to the ment and




including about 8 million

regional across traditional to population.10 thousands Indian the Arab also of

Uighurs, making
Uighur years, medicine. world strongly

up about 40% of


traces its develop on Ayurveda drawing partly the Silk Road However, meant and the West that influenced by ancient Arabic

was medicine Uighur and Greek medicine.

Traditionally, training the master-disciple by practitioners established Medical Mongolian the east Medicine capital MSM have for been this in all three TRM Since to the In in Inner 1958, model. educated systems the tertiary Mongolia, was 1950s, level dominated however, in colleges the Ethnic educate a city in the

was College medicine of the

purpose. set up students.

It is located

to primarily in Tongliao,

is also a Department There region. at the Inner Mongolia Medical College this college city of the region, although students. Together, medical these two institutions each year practitioners

of Mongolian in Hohhot, primarily graduate from

trains about their 5

100 Mongolian



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year bachelor's programmes. degree in MSM every graduate established An in 1974 In contrast, year from the at least 1000 Meanwhile, "modernising" companies relying they on seek have there has been drugs. to a great In all deal three these of

Fan, Holliday
interest regions, without new in



traditional been set

In Tibet, the first formal health

Hygiene, degree created was level. in independent soon after, and School in

school, the Lhasa School of

to provide to the sub training was of Tibetan Medicine 1985, the University of Tibet

traditional to

up methods modern

reform and



a Department of Tibetan Medicine, inaugurated offering In 1989, the two institu programmes. undergraduate degree tions were to create the College of Tibetan in Medicine merged Lhasa. Annual from the bachelor's pro graduates degree now 60 for the full 5-year about grammes average programme, plus a further 35-40 from training pursuing a that programme top-up 3-year to degree In comparison, level. at MSM the Tibetan degrees

ingredients modern medications from traditional

exploit and properties by

theories of their

understanding. to explain so as chemical

Instead, the active to produce elements to be

abstracting This

drugs effective tendency


prescriptions. in each region.



It is clear of that MSM is now stressed Tibet, and in the Inner Mongolia, in the ordinary individual MSM has been and Xinjiang medical practice in villages practitioners given to although undertaken small integrative TRM in clinics systems is active or by In all areas,

upgrades sub-degree were 519 students

region) number other the in


It is also and

(the only MSM

important to note are practitioners Tibet (especially takes

that recruited Lhasa) a

in the
large from staff


of MSM Chinese



Training in the west produced. about plus In contrast, trains 994

into provinces MSM hospitals. in Uighur medicine






College of Uighur Medicine


in 1987 in Hetian, a city

over TRM, been and TRM has priority of the margins the healthcare system. virtually pushed an identity to its small in addition faces Moreover, size, TRM sense as in each region; in the Weberian crisis TRM is evaluated to the MSM and reformed standard. "disenchanted," according It is therefore increasingly free from difficult the intervention for each and TRM to stand of amendments

In total, of Xinjiang. 1200 are currently There about 200 in hospitals students Medical Chinese and

since been have graduates on campus, 1400 students

independently, MSM designed

Xinjiang both MSM and in 2003


gaining practical training. in Urumqi, which University medicine practitioners, produced on 17 216 has students currently

not only driving into MSM. of TRM Indeed, medical

are to change tendencies its substance. These of TRM, but also a fusion the marginalisation in all three in into the TRM

to distinct fusion are

degrees taking theories possible and




medical indigenous run in all fusions medicine In 2003, with 4192 968 beds beds in are the in have colleges into teaching technologies, of Tibetan invested MSM rather medicine, Traditional of modern research,

MSM integrating place, and Furthermore, practices. In education, directions. amounts modern of time and scientific classics theories (in the

In Inner Mongolia, hospitals in the number limited of region total; and 295 4 had 31 Mongolian 55 Chinese medicine combined MSM in total.1316 thus there providing beds and Mongolian physicians. hospitals, with medicine region had

greater related

resources and case



on TRM are now

medicine hospitals, and Chinese the MSM

for example, practitioners medicine, TRM

the Four medical required reverse to



However, >360

total,17 beds. Across hospitals,


hospitals, are and 17 Tibetan

with hospitals, in 472 hospitals >50 000 with

techniques. a great deal case. In "scientific" students

and tantras) to know is not the more

the though tend researchers


the plus

of region a multitude in rural

Tibet, of Of

there clinics the

17 Tibetan small-scale medical in Lhasa the focal

medical freelance hospitals in 1916, point for



and their for research topics projects, graduate as their more "scientific" scholars supervisors. are not for sector, instance, only pharmaceutical prefer modern now used and facilities being technologies but also and traditional prescriptions drugs, are the and conducted under designed scientific from theories to discover effective traditional and drugs TRM has been who


practitioners in the region,


to manufacture research direction chemical

the main hospital, to the autonomous region belongs the practice of Tibetan medicine. 250 beds. The administration. total.14 there However, were 80 MSM remaining In 2003, the

established and forms

projects of modern

In 2003,

it had

16 hospitals belong 17 hospitals these 97 hospitals had region with 41 >5000

approximately to lower levels 552 in beds

of in thus

ingredients In clinical practice, of healthcare value with facilities MSM MSM


attitude explicitly themselves therapeutic

reforming administrators, over TRM.

prescriptions. the dominant



In Xinjiang, medicine Uighur the region had with

hospitals, there were in 2003, 682 with

beds. in total,

advanced in order hospitals.

modern TRM

or often implicitly have hospitals equipped Western and diagnostic themselves and are also divided hospitals to the MSM and standard,

that hospitals specialised in 2109 beds.14 However, thus there were >600

to "scientificise"



hospitals17 000 beds.


with compete into different often offer

departments much the same

according range of


as MSM

hospitals. MSM

Perhaps the only significant difference Pharmacy

Although to produce recently marketing of China modern the major many been built TRM drugs to expand a and spearhead production at the growing in other drive that aims market parts overseas. use and Furthermore, many compounds in all three hospitals on additional site, continue regions have factories the drugs, patient also will, receive TRM "double For in addition indigenous physicians diagnosis"

is that in a TRM hospital

conventional for treatment. usually in their

to receiving medicaments in such and TRM "double

Indeed, administer practice. according theories.

hospitals therapy"

every patient to TRM explanations

methods of presentation, in the form of tablets and A critical is national to overcome factor accreditation capsules. concerns the about that have traditional quality plagued for many The Chinese started years. compounds government on this in 400 effort 1998. are In Xinjiang, use) in the were 3 years to the end of

work which

2000, 30 of about
about accreditation

1000 different Uighur medical

in regular is continuing. accredited,



then prescribe or they conduct and MSM chemical diagnosis) drugs, a on As other MSM the MSM therapies (based diagnosis). MSM MSM conduct result, therapy, although physicians only TRM physicians for granted. take double This practice therapy has the popular medical that, for most strengthened impression They the TRM MSM problems, some minor, offer should do the main work, assistance. although TRM may complementary

one two diagnoses: they make to MSM and another according on both TRM (based compounds

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on medical and

integration the

in China


In evaluation is used to evaluate




of MSM TRM, the

modern Because modern new the


and manifested
physics, science has as

in the core disciplines

chemistry been broadly and biology. accepted to offering the point

in a of

every aspect has emphasised government "scientific" "scientific" created research, through of TRM. Such and the "scientific" reorganisation for TRM enormous difficulties caused physicians, young official a review experts physicians physicians have they measures. are subject MSM physicians medical committee are either applying institutions. consisting unable for promotion, often

of TRM.

In addressing "scientificisation"

(kexuehua), explanations have especially TRM in facing These TRM

such science, sense of this China, challenging of science, debated. we could


definition issue being

2 is equivalent premise is at best missing which block what stand. that the two this conclusions paper directed three intends

They or

to practice find themselves of MSM


according solely are often evaluated and grasped TRM Moreover, to a malpractice than TRM

to unwilling to TRM standards. according practiced physicians lawsuit, MSM are the

experts. evaluate

premise believe crux

Alternatively, 1, which that of the

by because the

is indeed 1 cannot ideology

rejecting to do. We it is the

premise scientific

Moreover, has the

TRM Instead, to which to the extent procedures that afraid norms and if they will

inappropriate be rejected their proper premise addressed

in systems integrative in order to return the major Before explaining places. issue section. generated

of shaping it must regions,


1, a particular in the next

to medicines indigenous we and why refute how be (b) will by conclusion

primarily be drawn from MSM. This has induced them to adopt

more in their practice.


Conclusion to the MSM more (b) states standard that so TRM as should to become be improved according more and scientific more The issue effective. is, if TRM has become in nature? it become is it still TRM Or has in this way, TRM a part In short, to improve is it possible of MSM? of to the MSM without the nature standard changing according thereby scientific


What TRM has caused practices, that all view scientific system has forms that, and of folk the popularity between the asymmetry the institutional and (or fusion marginalisation been the This Chinese ideology authorities supports is, MSM) in then to the is an

science evaluate general more

of TRM? The answer lies primarily in the ideology of

adopted of medicine. medical effective by

if one more

(that approach than another,

different The reform while TRM sterilise readily concerned more use drugs does medical own first or

types of type revision

that the answer

improvement is an MSM standard of


on which
to TRM.

of two

are made

integrative be should scientific approaches correcting demonstrate ideology, demonstrated observer lowers

and less effective the less scientific approach to of more standards the according improved In this ideology, MSM effective and more approach. are to methods of inter those alia, that, appeal in order to bias observer methods) (eg, statistical their a medical greater predictive is more approach appeal statistical to methods) capacities. effective Also if for that it more it in can this be

allowing standard.

the For

or suggests a that inspires a particular or practice, TRM measure or revision to be accredited reform by the instance, needles the method is learned of using from MSM, alcohol but to it can

acupuncture be accredited with

bias risks

through (such as


correcting reliably medical

effective of modern in more learn and

TRM is also standard because by the TRM can easily a and the needles accept cleaning is the of doing it.v Another way example good to manufacture TRM and facilities technologies efficient can and even ways. benefit can In from this sense, a medical of the methods improvement medical theoretical medical impossible. to draw tradition. should be system a different to its on

approaches. to be due allow into

other than and mortality is held of MSM effectiveness greater which accounts and to its causal of disease therapy, can be condensed This effective. it to be more ideology of morbidity the Moreover, following argument: the more than effective TRM (premise (premise 2). 1).

system, standard,


according systems operate


lines parallel This reveals theory, however, borrow point into The are it

defined the

distinct though by their unique

underpinnings. In learning. In practice, and insights The crucial incorporated and

The more MSM

scientific, scientific

complexity is difficult, indeed

of mutual largely

is more

it can measures is that

Therefore, (a)MSM ismore effective than TRM, and (b) in the integrative system of TRM and MSM, TRM should be
according improved more and scientific Conclusion to the MSM more MSM standard effective.111 has become predominant so as to become therefore why

for physicians be helpful one from more than measure standard. MSM be

its own second

system type on

learnt the newly of medical occurs but example when




therapies accredited

(a) explains


in medical
explains why 2. Logically, premise

TRM we For has could

in all three regions.

increasingly the block some of even been two fused conclusions have

into MSM. by tried rejecting


effective to make MSM

A typical chemical MSM

ingredients medications. be an and

is attempting from TRM already advocated by activity principles be accredited This

strategies the TRM by to find and abstract in order special standard. a

prescriptions constitutes the MSM


Chinese science more more

a special understanding coining or as MSM, is as scientific However, the not, with this conventional the modern a series of strategy modern sense

to contend scientific than

through that TRM

can and activity such because However, TRM basic theories with and medications, it cannot

is also


than MSM.1V

prescriptions regarding standard. by the TRM

is nothing of

of understanding is now science solidly

about quarrelling it or science. Like established, and have rules been

regarding '"Itshould


knowledge arranged empirical inference. and evidence They

are readily heard. For instance, there ivlnmainland such arguments China, TRM holds a is a contention that TRM is more scientific than MSM because holistic view, whereas MSM holds an atomistic and reductionist view. Such an argument the key does not possess solid intellectual strength because are often unclarified. (such as holism and atomism) concepts appealed this yes, because by the MSM standard? Seemingly, instrument is consistent with the SASM requirement of cleaning any medical we take into account if the fact that used in contact with the body. However, sense in the MSM cannot make the practice of acupuncture system, and as a cannot be accredited practice by the MSM therapeutic thereby have to be "No". the answer would standard, vls this also accredited www. medeth j es. i com

be noted that the ideology of science has never been explicitly in this as it is summarised document in an official Chinese 1 has generally been accepted However, by both the premise in academic discus and society. Premise 2 is controversial government Inaddition influence. view barely has any practical sions, but the opposite the conclusions have been carried to being supported by the two premises, out in the medical in China. Dractice expressed argument.

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458 Although
order thus instead

Fan, Holliday it is legitimate forMSM to conduct such activities

the medications



to develop produced of seeing

its pharmaceutical are indeed MSM such activities

industry, not TRM drugs. Hence, drugs, as successful "improvements"

to pursue), expectations framework rules (empirical frameworks lead ceptual in particular values and inference, each other. with

but to to


follow). different goals may sense,

specific explanatory con Their different systems, empirical in distinct and rules overlap different but never


of TRM, should be seen as MSM in nature. If a activities they uses to replace its original them medical and prescriptions it would or fusion the dissolution of productions, only imply

expressed of evidence coincide are

and which this



medicines and we show goals phar


that TRM into MSM.

To demonstrate experience. turn to Tibetan medicine how it holds different in those and its views of MSM.


Once only premise premise 2 (MSM 1 (the more is more scientific than the more TRM) scientific, for derailing conclusion any hope (a) (MSM 1 holds, than TRM). If premise the dominant of MSM position in the integrative of the three is warranted. systems regions Unless it can be challenged, the more the fate of TRM in these is granted, offers effective) is more effective

in both each other concept this point in a concrete manner, as an illustrative to example incommensurable substantive of prevention, treatment and

(manifested from macy)

Preventive goals Tibetan medicine

Buddhist view



life/11 Disease

is seen

by the

of world

regions the more effective is is a


inevitably be doomed.
Is it true that scientific a medical measure, is more it is? In particular, is it true that MSM on the concept TRM? A careful elaboration First, it is essential

effective than

of effectiveness

required. value-laden

term. Saying simply a sufficient that A constitutes condition for B, but also stating B as a goal to be pursued establishes if eating by A. For instance, an appropriate, to be effective breakfast for is taken regular that health eating or has been This entail established is to say as that breakfast. efficacy statements, that have been can

to recognise that "effectiveness" that A is effective for B is not

but is not accidental suffering. Suffering springs are imperma is transitory that all creation and all phenomena nent. to the offered special aetiology According by Tibetan are ultimately all diseases caused medicine, (a by karma karma from negative actions), previous person's including 20 at an earlier of this life.19 lifetimes and karma obtained period sees of the Buddhist that the fundamental way Accordingly, preventing lies in eschewing actions diseases negative by a Buddhist of life. way seriously living in A person's to an ego manifested is ultimately karma due of believing that the form of ignorance is, the ignorance (that as a truly existent there is such a thing ignorance self). This leads to the three These attachment, poisons: in three poisons hatred turn give and rise close to the

as a type of from the fact

it implies health, maintaining an end to be pursued through about effectiveness judgements relevant

or expectation-dependent manifest the values expectations been "life world"?namely, established or that as


making goal such goals or in the ordained If nothing has as be stated


effective activities "efficacy" mechanism


lived people's an end, then as a means.


of the three humors

experience. nothing

in the body

(Air, Bile and

are engaging people have not only assumed in the natural world, structure an end

the medical Accordingly, or in to judge "effectiveness" of a cause-effect the necessity but have also life world. behind is a medical it There Some tradition may is is is assigned the to the hidden

so that and disease occurs.19 their balance is broken Phlegm) sets forth a close between This understanding interrelationship hatred and the mental the physical (the humors) (attachment, to MSM. is alien and which close-mindedness), totally means the vicious from Extinction of suffering liberation cycle of existence, and and this knowledge that protects genuine accomplished of the practice from disasters.2122 medicine and sacred offers is through Dharma, the the proper religion in order

of an end-means necessity In order to disclose judgement necessary an age-old want to concerned, that to ask clich? contend the a the that that goal and

particular question health no

treatment "effective is the end which


for what?" of medicine. medical


persons to prevent Tibetan disease, on everyday dations affairs 23 24 to observe.19 This is not to say

In particular, recommen detailed for


individuals a it

disease prevent true. However, medical expressed health, traditions in disease

to preserve is always health, treat is formally illness. This contention true because it cannot different be substantively of medicine have developed different substantive their and various, illness. goals of

that of

Tibetan basic


does elements.



cosmology holds that

incompatible That is, they

understandings understand do not and

physical consisting is composed of the five cosmic elements everything correct or energies: It is roughly fire, air and space. earth, water, to state it is on these medical that Tibetan that five energies The air


in similar ways, illness and disease health, mean commensurable. mutually Accordingly, medical traditions share the same formal health, is useless traditions. developed disease, have culture, preventing in comparing Evidently, within illness functioned based and on a disease and the every health, its treating effectiveness

by similar we distinct although of preserving goals this formal illness, goal of different medical has of medical key substantive its tradition concepts

are established. and pharmacology anatomy, pathology the body the humors: basic energies influence through



long-standing culture: particular as particular a net of specific

three great strands of medical practice vlLooking back through history, found in the ultimate foundations for the various forms of medicine provide the world bases of all today: Chinese, Greek and Indian. The conceptual at variance with each other. Beyond that, three traditions are fundamentally medical traditions have also developed, often based on subtle subsidiary that set them apart from the and philosophical distinctions religious mainstream medicines belong that originally inspired them. Mongolian, to the latter category. Tibetan and Uighur


assumptions. the function suitable way goals and and to deal set

Accordingly, of a particular with

particular a medicine culture. what

concepts, in that granted goals evaluative and explanatory is best In order is an taken to decide appropriate to be part of is a what medical substantive


and problem the problem, culture

a distinct must be have


in a particular distinct medical based

of group referenced.18

traditions on their

set up different

tantras (compiled Four medical of Tibetan medicine, the Root Treatise, the four treatises: comprising the Practice Treatise, and the Appendices Treatise, Treatise) Explanatory can to reorganise be taken as using basic Buddhist principles reasonably all existing medical local Tibetan and materials, practices including For information about learnt from Indian and Chinese medicines. practices v"The cardinal classic in the 8th century,


the sourceof thisclassic, see Rinpoche (2001 )pp. 3-4; Cai (2002)pp. 54


philosophies/1 contains not only

unique, underpinning religions a complex each hold which matrix, They a distinct evaluative system (particular goals

70 and Qiangbachilie translation complete

have not found a reliable (1996( pp. 1-18.38"40 We see of the book into English; for a Chinese translation,


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on medical


in China


affect Air; fire (heat) affect Bile; earth and water

humanity) balanced, However, and the materialist medicine mysticism whereby the five affect the it is Phlegm. humors totally of When are these disturbed

(dampness and
not well occurs.25 a

Tibetan spirit pulse, such

medicine pulse, friend

for doctors lifespan pulse, reversing

to grasp, guest pulse,


as death



are energies and disease these in on which

mistaken their of

to understand merely

process vision.

interactions Buddhism

energies terms of Tibetan

The based precise ego have

is solidly affording the person's elements The

type is Tantric, is negated three

(role) pulse, a highly is not only technical, long term experiential to appreciate but it is also necessary matter,28 the Tibetan Buddhist world view and its fundamental values. distinct pulse phases the


enemy pulse, family so on. To master and


a highly form of practical for attaining that wisdom and they enter upon and the bliss


of their own divinity. Specifically, Tantric Buddhism holds

levels: is a gross, pure subtle, aspects. operated essence aspect Tantric Tibetan mind, identified 26 This


that a close of instance, family pulse implies family member can substitute the examination of his or her pulse patient for the patient. This is significantly "effective" when the patient cannot be examined to the the physician due directly by limitation of the the in circumstance doctor). the humors given that as the patient is too sick to (such Tibetan medicine holds the that of they the are patient closely can be read on the related



Mind".9 aspect and pharmacy. therapy an attempt to liberate for Tibetan Buddhism, Interestingly, the vicious from oneself by no means cycle of existence implies one must or depressed live an ascetic that life. To prevent Buddhist is crucially rather than hold it important or suppress to follow them: the physiological

the by informs


see to go imbalances relative's




Tibetan medications in for the modern exerting sense. their effects is not Dharma Instead,

disease, desires

solely pharmaceutical and Tantric ritual be

Do not obstruct the impulses of hunger,

sneezing, yawning, breathing, excess to remove the throat, sleeping, saliva from

thirst, vomiting,
mucus from and the mouth

to clear

performance ( such as reciting prayers )must the entire of preparation. Such present process throughout ritual preparation is intrinsic to the prepara and fundamental tion of Tibetan medicinal the well compounds, including prophylactic Tibetan Such medicines, are rituals from of its such taken the as Tsothel and the and They to to empower

known other

throat. Do not suppress the desire to defecate or urinate, do not hold or suppress intestinal wind and gas or block the emission of semen... By obstructing (or alternatively forcing these actions), all ailments arise and the winds are immediately disturbed.19
In addition, of the male to the and symbolism female some used for of Tantric energies Buddhism is the unity in a positive forms of sexual

precious pills.27 to become medicines enhance the curative

"animate powers with

inanimate," ingredients.

the medicinal

of Tibetan

the very pith and kernel of the Tantric Buddhist basis

medicine three stages:

manifested erotic

approach intercourse

sexuality: are freely


Giving the medicines empowerment directly; Visualising the medicines as the deity; Visualising one's self and the medicines as the deity.27
In Tibetan it with Five medicine, the pharmaceutical deal only processes that influence the gross somatic aspects of the physical whereas the ritual body, essence concerned with the of the pure

for pursuing health. Not only evil associations (no implications for health.27 has a positive value

and conveying religious feelings no does sexual have intercourse of licentiousness), but also

the gross element matrix Element is


Tibetan medical are embedded in therapeutic goals on which convictions Tibetan medicine and three distinguishes mundane. The cures: two levels cures

preparation medicines. treats may like ritual on want psychic

Buddhist the Tantric specific medicine stands. First, Tibetan of treatment: is and greed hatred and the leaving Instead, In order fundamental the Buddha's treatment ignorance clinging, anger, medications It

essence the pure of the preparations Accordingly, essence the pure level of the patient.28 Some (mind) to contend that this is not objective because it sounds means, a placebo effect. such However, playing of drugs is obtained from the ancient Tantric an inseparable, has been view, which always medical Even if tradition. part, of the Tibetan sense, In any or psychological it is still case, rather a unique than medical contribution of any school in to of


preparation "Wisdom Mind" indeed its role a central is only

confusion; and and other lust;

Wisdom-insight cures attachment, Virtue-compassion cures and Contemplation-meditation Mundane treatment uses

the modern patients'

religious scientific


is not

treatment, (gurus). treatment. mind the unless the

medical ordinary techniques. case to mundane that doctors appeal only treatment to the Buddhist fundamental priests





great difficulty

in determining
of patients'

the degree


in the majority


a good physician to provide is required complete to offer the physician's treatment, complete and subtle levels of element stay only at the gross Tantric "Wisdom Mind" apply will to appreciate and treatment resulting view, itself on only be

The above medicine contrast

shows sharply in all that with creatures the those substantive sought goals of Tibetan Tibetan by MSM. and identified


From the patient's body. is able mind the doctor's essence element level, the or superficially complete, than fundamental rather


holds that the Tantric Buddhist principle of the essence

is involved the and operated

partial matic most

probably temporary.27 the gross and element subtle go beyond to see the fundamental in order body and thereby the problem This doctors requires conduct to grasp is Tibetan tool the the

or sympto diagnosis incomplete and correct, and the clinical result In short, a real doctor must be able to aspects the patient's cause of (mind) A can the of

through the "Wisdom Mind." This belief significantly directs and

shapes includes desires woman fulfilling specific Tibetan karma and ways. therapy medical (negative seeking In the goals. actions), proper treatment, In prevention, the goal avoiding smoothly, in sexual complete discharging physical union of man and the involves goal rather than

prominent example is a basic Pulse diagnosis identify general) Various and causes complicated evaluate of

spiritual treatment.28 proper certain delicate techniques. medical examination. pulse which the (not the of doctor only

by pursuing



spiritual deepest humoral imbalance of pulse have



patient.27 in established

is taken to be very effective v,"Ritual treatment in Tibetan medicine. A is regular kneeling in prayer. from other prominent example Differing inwhich one kneels only a few times, the Tibetan way is to do it prayers or thousands a hundreds of times. Although this is primarily religious it is also taken as a very effective medical for treatment, especially activity, Ga diseases (see (1996) p.156).41 digestive

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mere cing these health medicine entirely Accordingly, interventions ment in mundane the effect treatment. of medication leads In pharmacy, through the Tantric goal covers rituals. positive a result, structures with some that Tibetan enhan Seeking ideal of Tibetan that of MSM. medical judge being to is TRM who by we have have systems investigated are capable of quickly and accurately hand the need of appealing without modern return be technological to their homes that this involves and superb



specific goals in the Tibetan contains alien as terms the of to when a


to a comprehensive of life.lx As way

complicated immediately problem parallel traditional on how may MSM

orthopaedists broken bones setting or using to surgery can The facilities. patients recover more quickly. rather The only than the pain we favour such depends pain plus plus and


of end-means system incommensurable physicians see

MSM ineffective, the


the they may simply make substantive ends of MSM, while goals that that Tibetan medicine medical the Tibetan

bone-setting we trade faster slower

whether Accordingly, or MSM methods orthopaedics an of off between experience versus experience are also additional no

of ignorant For instance,

particular if one claims

pursues. attempt

somewhat somewhat social less



the humor disturbance of a improving his examining family member's "family than the MSM care, one must palliative of Tibetan is to offer medicine goal

terminally pulse" overlook fundamental

ill patient by is less effective the fact that a treatment

essence to the patient's is closely related aspect, which regarding is to say, given the essence of his This aspect family members. set of substantive that Tibetan medicine does not hold the same medical MSM ends is more or goals effective medical as MSM, than goals through that judge than those it is not to possible or vice medicine, concrete mechanisms goals the values state versa. that that As a

are usually much implications; than MSM interventions. expensive in these the values manifested and most Finally significantly, cannot with other be pursued indices consistently always in medical For all human values involved instance, practice. three TRM systems beliefs matter have in favour how developed useful knowledge It may delivery be and skills case

There recovery. TRM methods for instance,

pain medical

in aiding baby delivery

religious that no become, infant

at home,
of home such

fitting well
delivery. home

into the local

the techniques rates of higher at a the

Tibetan indicate certain the of

substantive medicine then more

is pursuing we can unless

and means, of MSM are

substantive TRM in in

home still involve delivery slightly than delivery and maternity and mortality morbidity in this MSM well-resourced case, However, hospital. effectiveness terms be of a medicine can no longer indices. be judged

perfect will

appropriate disease and illness preventing curing cannot is more claim that MSM Comparing incompatible Can we TRM and MSM medical is

promoting formal than

health, sense, we the TRM. their





a set of tease out for substantive goals to argue MSM Some may want and TRM? that indices evaluating rates in general, such as life expectancy, and mortality morbidity rates and and maternity in particular, infant mortality plus emergency neutral standards That these rescue success rates and other indices TRM can be used as to compare the effectiveness contend that both MSM and fair if criteria to evaluate their of MSM and TRM. accept medical medical standard medicine medicine

goals. "neutral"

If people values of the of the "neutral" at home to deliver (for they may important fundamentally at home, in a religious want to hold ritual that can only proceed in comfort to cherishing the mother's addition psychological environ in a familiar members the company of her family will medicine be the one the most effective ment), at home than in hospital. assistance rather offer most functions that a medicine This leads us to recognise particular mutually different culture. Because different cultures hold that can

in only take it to

within and


is, they may as indices even


practices, goals.

strategy contribute on

However, are multiple.

they hold the difficulties First,

incompatible with such factors indices.

respective substantive than

the use of incommensurable require they may goals, which incommensurable and mutually means, among means. formal are medical the same if all medicines have Even health, other from each they differ how is and what health regarding cannot indices The "neutral" medical effective in these as with medicines other do not because, indices values have other among to be balanced in their health indicate things, with

a "neutral" other An

of pursuing goal substantive goals should which

to the variation

many of these


be pursued. is more medicine manifested as well

is at best

a necessary, these indices. and

but not Second,

sufficient, there is

condition the issue

scores for good of discrepancy P is in theory things better the all other generate However,

the values each culture. the other

between more

theory practice. effective than medicine a set number the same

Suppose Q

medicine that, P will



equal, being than indices

(meaning of doctors using of doctors


effectiveness certain pursuing premise

using Q). work be that doctors effective Q do more using reality may well not P because than doctors received such the latter have using as the former, even and proper though good regulation training is theoretically this was the their medicine superior (indeed, TRM Third, physicians the values in the manifested three regions in these during indices


of such configurations is only embedded of MSM values and substantive goals, different 1 (the more substantive scientific, values the more

in a particular to evenly with regard the values. Accordingly, pursued in certain not and in goals. cultures other In this with cultures sense,


is false.

Different modern based, recognised standard If this MSM with forms Chinese and new the of medical in have been attempted integration TRM standard standard based, MSM history: have The Chinese standard based. broadly of the TRM standard based integration

of many complaint our investigation). may people term whereas the very medicine be more Another not be believe health MSM elderly. is more evenly that and

many Today, promoted by each medicine. in promoting TRM is better than MSM long life expectancy, average increasing thereby than TRM in critical is true.x care, Then, this belief will for especially judging which to is taken index care? three


(primarily in the 19th century)

based article's standard vibrant integration argument based established

and the defect of the new

is better Suppose effective

important: good example

average in this

on which depend or critical life expectancy is orthopaedics. All regard

in the mid 20th century). (primarily the currently dominant is sound, then is also indefensible. Regions integration as Tibet, Inner TRM systems (such

to Tibetan medicine, health has two flowers and three fruits. lxAccording The first flower is freedom from disease, the second long life. The first fruit is Dharma of noble human Dharma, (the development including Worldly and Divine Dharma characteristics) (the following of the Buddhist religious iswealth, and spiritual wealth. path). The second including both material to free oneself The third is happiness, the capacity from confusion having and ignorance and attain liberation (Enlightenment).27

TRM experts do not agree with this assumption. For instance, an told us that the current model of from the Tibetan Medical School InTibet, integration at the clinical is problematic. level takes place practice a In such is faced with a critical situation. physician particularly when the patient, before cases, MSM may well be used initially to stabilise to Tibetan medicine that for longer-term care. The expert argued switching the effective critical care techniques of Tibetan medicine have been curbed from application and development by this model of integration. xSome expert

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on medical


in China



and Xinjiang)
whereby their own the Chinese medical

standards.1 authorities sectors


to a dual


system to according To be fair, the indigenous


and MSM

operate made

independently efforts to preserve of all and State


in the medical


three regions. overseen by Administration and and local thus

They are staffed committed deeply of Traditional However, TRM the

skilled practitioners, by highly in the and able officials Chinese Medicine and

9 Biofeld J. The tantric mysticism of Tibet. Boston: Shambhal, 1987. 10 Xinjiang Uygur Autonomous Region. (InChinese. ) 166324.htm chinese/zhuanti/ (accessed 19 February 2006). 11 Tibet University, = ????&menuld = 3 (accessed 19 February 2006). structures.jsp?flag 12 Xinjiang Medical University. (InChinese) http:// (accessed 19 February 2006). 13 Figures of TRM Hospitals in each province provided by the State Administration of Traditional Chinese Medicine of the People's Republic of China, http:// (accessed 19 February 2006). 14 Statistics of TRM Hospitals in each province provided by State Administration of Traditional Chinese Medicine of the People's Republic of China, http:// (accessed 19 February 2006). 15 Statistics of Traditional Chinese Medical Hospitals in each province provided by State Administration of Traditional Chinese Medicine of the People's Republic of China, (accessed 19 February 2006). 16 Statistics of Integrated MSM and TCM Hospitals in each province provided by State Administration of Traditional Chinese Medicine of the People's Republic of China, (accessed 19 February 2006). 17 Statistics of Healthcare Institutions in each theMinistry of province provided by Health of the People's Republic of China. nttp:// (accessed 19 February 2006). openstatistics/year2004/p4.htm 18 Engelhardt, Jr, HT. The foundations of bioethics, 2nd ed. New York: Oxford University Press, 1996. 19 LiY. Four medical tantras (Si Bu Yi Dian) (Translation. ) Beijing: People's Health Press, 1983;46. 20 Khangkar D. The Buddhist way of healing. New Delhi: Lustre Press, 1998:43. 21 Dalai Lama. The Buddhism of Tibet (Translated by Jeffrey Hopkins. ) Ithaca: Snow Lion Publications, 1987:23. 22 Tsarong J. Fundamentals of Tibetan medicine. Dharamsala: Tibetan Medical Center, 1981;(lndia). 23 Sachs R. Tibetan Ayurveda: health secrets from the roof of Hie world. Rochester, VT: Healing Arts Press, 2001. 24 Dash VB. Tibetan medicine: theory and practice. Delhi: Indian Books Centre, 1997:69-79. 25 Donden Y, Tshering G. An introduction to Tibetan medicine. New Delhi: Tibetan Review Publications, 1976. 26 Guenther H. The concept of mind in Buddhist Tantrism. ln:Guenter H.TVbefan Buddhism inwestern perspective. Berkeley: Dharma Publishing, 1989:36-59. 27 Dummer T. Tibetan medicine and other holistic health-care systems. New Delhi: Paljor Publications, 1994. 28 Khangkar LD. Lectures on Tibetan medicine. Dharamsala: Library of Tibetan Works and Archives, 1998. 29 Richardson J. Evidence-based complementary medicine: rigor, relevance, and the swampy lowlands. J Altern Complement Med 2002;8:221-3. 30 Shine Kl. A Critique on complementary and alternative medicine. J Altern Complement Med 2001 ;7:S145-52. 31 Furnham A, McGill C. Medical students' attitudes about complementary and alternative medicine. J Altern Complement Med 2003;9:275-84. 32 Barrett B. Alternative, complementary, and conventional medicine: is integration upon us? J Altern Complement Med 2003;9:417-27. 33 Farquhar J. Knowing practice: the clinical encounter of Chinese medicine. Boulder, CO: Westview Press, 1994. 34 Hsu E. The transmission of Chinese medicine. Cambridge, UK: Cambridge University Press, 1999. 35 Ma B, Gao X, Z. History of debate between traditional Chinese medicine Hong and modern scientific medicine (Jindai Zhongxiyi Zhenglunshi). Hefei: Anhui Science and Technology Press, 1993. 36 Unschuld Paul U. Medicine inChina: a history of ideas. Berkeley, CA: University of California Press, 1985. 37 Sivin N. Traditional medicine in contemporary China. Ann Arbor, Ml: University of Michigan Press, 1987. 38 Rinpoche VR. Tibetan medicine: illustrated in original texts. Delhi: Indian Books Centre, 2001:3-4. 39 Cai J. A general history of Tibetan medicine (Zangyixue Tongshi). Xining: Qinghai People's Press, 2002:54-70. 40 Qiangbachilie. in China (Zhongguo de Zangyi). Beijing: Tibetan medicine Chinese Tibetan Study Press, 1996:1-18. 41 Ga Z. The mystic culture of Tibetan Buddhism: Tantrism (Zangchuan Fujiao Shenmi Wenhua-Mizong). Lhasa: Tibetan People's Press, 1996:156. 42 Bauer JL Through theTibetan looking glass. J Altern ComplementMed2000;6:303-4. 43 Bodeker G. Lessons on integration from the developing world's experience. BMJ 2001;322:164-7. 44 Hong CD. Complementary and alternative medicine in Korea: current status and future prospects. J Altern Complement Med 2001 ;7:S33-40. 45 Tibetan Medicine Administration. Tibetan medicine (InChinese. ) Lhasa: Tibetan People's Press, 2003. 46 World Health Organization. Traditional medicine: growing needs and potential, 2002. 19 February 2006). 47 World Health Organization. Traditional medicine Fact sheet No 2006). (accessed (accessed 134. 2003. 19 February


disenchants and

of science ideology of TRM. MSM practitioners is in retreat. regions, and equal

its regional is all-pervasive, too is simply


in these systems integrative to ensuring that modern paid to function unique on different but

to reframe In order proper attention to be needs greater are able traditional medicines bases. carrying it becomes As each particular difficult is founded values on and

to hold that rules, goals empirical a single measure ever be found to evaluate could competing as in so many In this domain, traditions. is no there others, universal and a positivistic search for the "evidence standard, is likely to be counterproductive.29 The choice high ground" to arrange is either medical in a hierarchy traditions and or to set them on equal status privileges distribute them, among a hierarchy, know of no good bases. We for building argument based then reasons valid medical setting why be the approach should taken.2 footing In all three regions, this requires the size significantly enlarging of TRM in recently medical institutions in urban areas, developed and think of many traditions on an equal including educational, it would pharmaceutical also make hospital therapies. medical Finally, standard, to Thus, and sense contain mutual clinical. For instance, can

conceptual and distinct



it is clearly helpful

for each region to fund specialist

for every large-scale, some departments referral between


MSM comprehensive traditional offering modern become based This societies on and more their traditional effective. own our

practitioners TRM systems rather for than

can regions be regulated the MSM standard. in these must in other

is also with



frameworks policy sectors. medical indigenous

The University in this article was research reported supported by a grant from City of Hong Kong We thank officials and (Project No. 7100257). in Inner Mongolia, Tibet and Xinjiang to us for talking practitioners about traditional medicines. We are also very grateful for the incisive and constructive criticism from Griffin Trotter journal, Professor Jr. The usual disclaimer applies. the two reviewers appointed by this H. Tristram and Professor Engelhardt

Authors7 affiliations
R Fan, Department of Public and Social Administration, City University of Hong Kong, Kowloon, Hong Kong IHolliday, The University of Hong Kong, Hong Faculty of Social Sciences, Kong

1 Fan R.Modern western science as a standard for traditional ch?nese medicine: a critical appraisal. J LawMed Ethics 2003;31:213-221. 2 Holliday I.Traditional medicines inmodem societies: an exploration of integration ist options through East Asian experience. JMed Philos 2003;28:373-89. 3 World Health Organization. WHO traditional medicine strategy 2002-2005. Geneva: WHO, 2002. 4 National Bureau of Statistics, People's Republic of China. Communique on maior figures of the 2000 population census, 2001 . en/e5cendata2.htm (accessed 19 February 2006). 5 InnerMongolia Autonomous Region. (InChinese) 166208.htm chinese/zhuanti/ (accessed 19 February 2006). 6 Qigeqitu. Modern mongolian medicine (Xiandai Mengyixue). Liaoyang: Liaoning Minzu Press, 2002. 7 Xizang Autonomous Region. (InChinese. ) zhuanti/166235.htm (accessed 19 February 2006). 8 Kapstein MT. The Tibetan assimilation of Buddhism. New York: Oxford University Press, 2000.

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