What is the dao 道 of medicine: its knowledge of illness and the body; the ability of physicians to exercise clinical judgement; its store of effective treatments? How does one internalise that dao: by cultivating an understanding of qi transformation or by learning to match patterns to formulas? And, finally, what does the dao of medicine contribute to our understanding of the world at large and our ability to act morally within it? These questions became a hot topic among physicians in China and Japan in the course of the 17th and 18th centuries and the answers given continue to shape the field of East Asian medicine until the present day. Yet, as I will argue in this essay, we may have to look beyond the field of medicine to find truly illuminating answers.
Two visions of the dao of medicine
Dao, like qi, is a term with a long and complex history and therefore best left untranslated. One of its fundamental meanings is that of a path or way for understanding how the world is and, by implication, how we should act within it. In Western philosophical terms it answers to one of the most fundamental questions facing humanity, namely how to live a good life. Neoconfucianism, for instance, is known in China as daoxue 道學 or ‘dao learning’ because it addressed itself precisely to this question. But so, of course, did various Daoists, Buddhists and cosmologist as well as poets, essayists and statesmen. The broad learning (xue 學) and culture (wen 文) this elite produced was considered different from and superior to the more concrete problems of living solved by doctors and engineers in much the same way that physicists or philosophers in the West sometimes look down on the applied sciences. Hence, medicine was traditionally classified to belong to the arts and crafts (yi shu 藝術).
In China, this situation gradually changed during the late imperial era. On the one hand, generalist scholars became themselves interested in applied knowledge including medicine. On the other, physicians claimed their art, too, should be considered a dao and not a mere craft.
The most vociferous proponents of this view were the so-called ‘literati physicians’ (ru yi 儒醫), who generally were deeply embedded, socially as well as intellectually, within the dominant literati culture. To make their point literati physicians insisted on the centrality of clinical judgement (yi 意) as the hallmark of the good doctor (liang yi 良醫). Such judgement could only be exercised by those who grasped the vital principles underpinning all cosmic processes. That, in turn, required deep learning. Put another way, while literati had traditionally channeled their understanding of dao into the management of the state, community and family, doctors employed the same knowledge but focused it on managing human life. Li Chan 李梴, author of a pre-modern textbook for aspiring physicians widely used throughout East Asia put it thus:
Medicine is the art of managing human life. One should not lightly think of studying medicine, for it requires substance and honesty, a quiet and persevering attitude, and an interest in real knowledge and secret virtuousness. … Medicine is also a branch of scholarly learning. Unless one studies and understands principles one will remain an uneducated philistine unable to penetrate the transformations underlying all phenomena.
Literati physicians therefore reconfigured medicine as a scholarly formation complete with its own canons, sages and authentic lineages. Yet, not everyone professing to be such a doctor possessed the talent or moral character demanded by Li Chan’s lofty vision statement. However strongly literati physicians insisted on their way of practicing medicine embodying dao they could never entirely dissipate suspicions in the minds of their peers that when all was said and done medicine was still a craft or, at most, a lesser dao (xiao dao 小道). It might be able to treat illness but it did not thereby contribute to answering the truly important questions of how to lead a good life.
At the same time, literati physicians also faced opposition from within the domain of medicine itself. Some doctors were more than happy to embrace the craft character of medicine even if they did not necessarily phrase it that way. The most radical proponent of this position was Yoshimasu Tōdō 吉益東洞 (1702-1773), a Japanese doctor who referenced his practice to the Chinese tradition and in the course of the twentieth century became an inspiration for many physicians in China and beyond. Yoshimasu Tōdō strongly rejected any kind of metaphysical speculation regarding the causes of illness, the functioning of the body, or its relation to a person’s life (ming 命) as irrelevant to medical practice. He dismissed five phases cosmology and valued yin/yang only in as much as it was a convenient tool for classifying phenomena. He argued that all disease was due to the accumulation of toxin (du 毒) in the body and that a physician’s sole task consisted in removing this toxin.
To this end Yoshimasu Tōdō advocated a practice that directly linked formulas with manifestation patterns (fang zheng 方證) without the need for clinical judgement to mediate between the two.
Therefore, Master Yoshimasu Tōdō viewed identification of the pattern as treating the root and did not seek to establish the cause.
There is no need in this vision of medicine to ‘deliberate on treatment’ (lunzhi 論治),which practitioners of TCM consider to be of equal importance to ‘pattern differentiation (bianzheng 辨證), and therefore neither for much learning beyond that of formulas and their indications. In fact, this vision is not at all dissimilar to that of contemporary evidence-based medical practice where physicians, who previously based treatment on their own clinical judgement, are increasingly forced to follow routinised practice guidelines. And just as the proponents of evidence-based medicine insist that only their practice is truly scientific, Yoshimasu Tōdō claimed that only his vision of medicine embodied its true dao. In the words of his son Yoshimasu Nangai 吉益南涯 (1750-1830):
An effective treatment strategy can be conceived by one person but used by ten thousand people. This kind of unity is what is called dao, and such dao can be produced by anyone. It applies to male and female alike, it can be studied and disseminated. What is the need for divine insight?
If literati physicians defined the dao of medicine as rooted in learning and personal judgement unique to each individual case, Yoshimasu Tōdō located it in the universal effectiveness of proven remedies. It did not take long, however, for Yoshimasu Nangai to reintroduce theory into his father’s medicine by way of his doctrine of the ‘three physiological substances’ (san wu 三物). Literati physicians, meanwhile, were always willing employ empirically proven remedies whether or not they were derived from scholarly learning. Hence, it is probably best to view the dao put forward by each side as constituting ideal types of medical practice that all ‘real’ medicine, Chinese or Western, combines in various ways. Not for nothing do we say that medicine is always as much science as it is an art.
In the sense of dao answering to wider questions regarding the living of a good life both visions merely drew on resources already available in the culture, from yin/yang cosmologies and ancient formulas to distinctions between dao and craft. They did not offer many new insights in return. The Monk Yaodi, on the other hand, did.
The Monk Yaodi
The Humble Yaodi (Yaodi Yuzhe 藥地愚者) was the monastic name of the seventeenth century polymath Fang Yizhi 方以智 (1611-1671), a scholar, medical expert and Chan Buddhist whose life and work is best captured by the saying that ‘they don’t make them like that anymore.’ Hailing from a family of scholars well versed in medicine who were also amongst China’s foremost experts on the Book of Changes (Yijing 易經). Somewhat of a dandy in his youth and a devout Buddhist later in his life, Fang Yizhi was one of the foremost Neoconfucian scholars of his age, a philosopher, linguist, poet, essayist and natural historian, whose interest ranged from physics to anatomy. Widely portrayed as helping to reorient Neoconfucianism from a focus on the development of our inner selves to a concern with things (wu 物), Fang Yizhi belonged to the first group of Chinese scholars that actively tried to make use of Western science recently brought into the country by Jesuits. He and the group of researchers he established proposed innovative theories about a wide range of natural phenomena including what we would nowadays call gravity and the location of memory in the brain. Fang Yizhi was also an expert on Daoist literature, specifically the Zhuangzi, and a serious student of Chan Buddhism. As a Ming loyalist he became involved in organising resistance to the Manchu Qing dynasty, a stance that forced him to retreat into monastic life and contributed to apparent suicide by drowning.
Fang Yizhi’s monastic name highlights the importance he accorded to ‘medicinals’ (yao 藥) in his thinking, which employed medicine and medicinals as tools for thinking about dao within and beyond the medical domain.
Medicines and medicine: a broader view
The importance Fang Yizhi accorded to medicine and medicinals is clear to see in many of his writings. They take up three chapters in his Notes on Principles of Things (Wuli xiāo shí 物理小試), where he makes medicinals central to our understanding of what things are:
Between Heaven and Earth, everything is a medicine, everything is a thing, and everything is a principle. There is not one thing without yin and yang, qi and taste, as well as mutual interactions and transformations. Their differences derive from places and times, and so it goes for [differences among] people. While some [drugs] might work in one case but not another, or efficacious here then harmful there, all such differences will not go beyond Qibo’s delineation of “five [kinds of qi] by five [kinds of taste].” If so, then this is indeed easy and concise!.
He Bian, from whom I have borrowed this translation, uses the passage as evidence for Fang Yizhi being part of a wider shift in thinking about materia medica in late imperial China that homed in on medicinals as material entities possessing distinct natures (xing 性) that everyone, not just doctors, could understand and employ. Although working in Japan, Yoshimasu Tōdō was strongly influenced by these writings and clearly belongs to that tradition, too. However, I think the above quote - especially when read against the rest of the Introduction in which it occurs and even more so his later works - makes a much more far reaching claim about why medicinals are important. Fang Yizhi thought of medicinals as providing us with privileged access for understanding how to understand and handle all kind of things including immaterial ideas and thoughts.
One way to get at what Fang Yizhi means is via his interest in and practice of Chan Buddhism. Buddhists call Buddha the ‘king of medicinals’ (yao wang 藥王), a reference not so much to the actual use of medicinal substances but to the ‘skilful means’ (fangbian 方便) by which he helps human beings to overcome the three toxins (san du 三毒) or basic afflictions that stand between ourselves and enlightenment. Such ‘skilful means’ are anything that helps a particular person at a particular time in a particular place to understand the Buddha’s teaching or part of it. In that, they are like medicines. They are useful for treating a particular affliction but must be discarded once the patient has been cured.
In The Joining of Things (Dongxi jun 東西均), one of Fang Yizhi’s late period works, he explicitly drew on this analogy between medicinals and skilful means in developing his thinking regarding the relationship between different intellectual traditions. He argued that all the great teachings - Buddhism, Confucianism, Daoism, Yijing studies, numerology, Western learning and so on - can be conceived of as medicinals (yao 藥) that provide relief from toxin induced afflictions in as much as they answer to the human yearning for knowledge, understanding, security and so on. However, just like medicinals, all of these teachings are ultimately partial and always provisional (pian 偏). For what is a remedy in one context can become a toxin in another. To quote Yoshimasu Tōdō whom Fang Yizhi would not have known but with whom he shared much in common regarding the understanding of medicinals:
Medicinals have a one-sided (pian 偏) nature. The one-sidedness of their qi is what makes them toxic, but it is also this toxin that allows them to eliminate toxins.
The same applies to any teaching conceived of as a medicinal. It can help us solve some problems, but for Fang Yizhi as for any Buddhist or Daoist, all learning is by definition provisional (pian 偏) and never true, correct or authentic (zheng 正) even though its proponents may designate it as such. Adhering to such teaching for the sake of identity, power, or fear and applying it to problems it cannot solve turns it into a toxin. The cure, however, lies not in replacing one teaching with another, nor in seeking to construct a grand synthesis, a theory of everything, nor even in transcending all learning by reaching the emptiness behind all phenomena. Instead, Fang Yizhi, turned to Chinese medical practice to develop an innovative solution to the problematic of how to orient oneself with relation to different traditions of learning that he called the ‘great productive entanglement’ (jidacheng 集大成).
The great productive entanglement (jidacheng 集大成)
The use of medicinals in Chinese medical practice has two characteristic features: the processing (paozhi 炮製) of individual medicinals and the combined use of several medicinals within formulas. In the course of processing things like fire, water or salt, things that can be considered toxins in certain contexts become productive resources for further developing the nature of medicinals. Generalising from medicine to the domain of knowledge and action, any learning can equally be improved by bringing it into conjunction with others
Fang Yizhi deployed this approach in exemplary fashion in his study of the Daoist classic Zhuangzi, which he entitled “Monk Yaodi Roasts Zhuang” (Yaodi kao Zhuang 藥地烤莊). Reading Zhuangzi through other texts from different traditions he exposed its affinity to Confucian knowledge, thereby turning Zhuangzi from an opponent of Confucianism into Confucius’ heir. Fang Yizhi’s playful reading of the text does not insist on being the correct or authoritative interpretation, nor does it claim to reconstruct the historical Zhuangzi. But by processing the text like a medicinal, he considerably widens his scope of application.
As for the combination of medicinals into formulas that are at once balanced (he 和) and effective, this is a practice even Yoshimasu Tōdō, not otherwise known for hankering after complexity or gentleness, did not on stray from very often. Extending this practice to the conception of thinking and learning as medicinals works towards an ‘interpenetrative understanding’ (huitong 會通) that hankers not after a totalising syntheses that would eliminate all difference but that allows us to feel comfortable in the midst of the tensions that exist between different ways of engaging with the world. Fang Yizhi calls this state of being the ‘great productive entanglement.’
What I refer to as jidacheng is the ability of gathering the best tools of past and present into one 'large clump of prickly chestnuts' thereby ensuring that the most exalted tools of countless generations are endlessly transformed in their usage, that inferior tools are endlessly feared but also exalted, that the artful is constantly copied while also exposed as fake, that the sages are defended to one's death and then killed. Without realising it that which has nourished and sustained the people of this world for endless generations has also always been their poison.
Prickly chestnuts when they clump together spin with the wind, prickly on the outside and therefore difficult to pick apart. This is precisely how Fang Yizhi wants ideas, conceptions, knowledge and learning to interface. Forever questioning and challenging each other in ways that may be painful but that are also forever productive, if not necessarily in an always predictable manner. Again, the Chinese medicine analogy is helpful. Ephedra Decoction (má huáng tāng) may be the correct remedy to choose in a given situation but what happens once we administer it can never be known with certainty. It may resolve the illness with one sweat, but this sweating may deplete the body’s yang qi requiring an aconite formula. Perhaps the sweating will not resolve the illness completely necessitating a further dose of Ephedra Decoction (má huáng tāng) combined with Cinnamon Twig Decoction (guì zhī tāng). Some of these solutions we may already know, others are new diseases produced by ourselves for which we have to find new remedies. And even those problems we did not create ourselves can be viewed as diseases from which we can learn to devise new medicinals and formulas.
To move in that direction we must be willing to allow for difference and friction to exist, to overcome the desire for attachment, to become experts in understanding the nature of medicinals but never be limited by them, to be willing to learn from everything and everyone while maintaining the right to make critical judgements. It is a method for finding meaning in life and to act purposefully within it even if life and its basic constituents do not appear to have any intrinsic meaning and all solutions are always at best provisional.
Revisiting the dao of Chinese medicine
I believe Monk Yaodi conveys a powerful message for our times. It is rooted in the very materiality of medicinals as powerful things whose power can be harnessed but never ultimately controlled. This is something realised, too, in the Western medical and philosophical traditions through the notion of the pharmakon, which can be both remedy and poison. However, whereas in the hands of thinkers from Plato to Derrida such pluri-potentiality tends to be channeled into either/or choices, in Fang Yizhi’s hands the processing of medicinals and their traditional use in compound formulas leads towards the quite different proposition of ‘interpenetrative understanding’ and the ‘great productive entanglement.’
This proposition does not demand either/or choices nor is it satisfied with the poly-perspectival coexistence of different points of view. In its action orientation and search for progressive solutions to real life problems - the processing of medicinals - it differs from Buddhism’s goal of transcending toxic attachments or Daoist attempts to ride the qi of eternal change, positions that easily lead to detachment and withdrawal. Locating oneself in the middle (zhong 中) of this entanglement resonates with Confucian demands for getting involved but without insisting on any of its metaphysics or notions of cultural distinctiveness. No identity politics for Monk Yaodi, no choosing your tribe because that is what feels comfortable. Instead, he urges us to learn to be at ease in the midst of a world of competing demands and to intervene even though this world is too complex to ever fathom in its entirety.
Like any living tradition Chinese medicine has never been short of arguments about what is authentic because it tracks back directly to the roots, which ideas are orthodox and which constitute deviations, what really works and how medicine should be practiced. Despite an emphasis on the past it has always been open to influences from elsewhere and accommodated to changing epidemiological landscapes, patient preferences and healthcare systems. As a living tradition Chinese medicine, it seems to me, may be an exemplar of what a great productive entanglement looks like in the flesh. It may even be called its true dao, a dao rooted not in statements about what medicine is or should be but in the material nature of its medicinals, their processing and networking into formulas - which, by the way, is the one thing that all its practitioners share.
1. Li Chan李梴. Yixue rumen 醫學入門. Xiyi guige 習醫規格, 1575. Accessible at: https://ctext.org/wiki.pl?if=gb&chapter=956980
2. Yoshimasu Nangai 吉益南涯. (1747). I han 醫斷. Reprint by Xueyuan chubanshe Beijing, 2009, pp. 16-17
3. Yoshimasu Nangai 吉益南涯. (1747). Kun i han 續醫斷. Hoho 方法. Reprint by Xueyuan chubanshe Beijing, 2009.
4. Fang Yizhi , Wuli xiāo shí 物理小試. (1643). Translation by Bian, He. (2020). Know Your Remedies: Pharmacy and Culture in Early Modern China. Princeton: Princeton University Press, p. 149
5. Yoshimasu Tōdō 吉益東洞. (1747). I han 醫斷, p. 13.
6. Fang Yizhi 方以智, Dongxi jun 東西均 (1652). Accessible at: https://ctext.org/wiki.pl?if=gb&chapter=491797
7. On the pharmakon in the western medical and philosophical tradition see Rinella, M. A. (2010). Pharmakon: Plato, drug culture, and identity in ancient Athens. Lanham: Lexington Books. His chapter on Derrida’s Plato’s Pharmacy is especially enlightening with respect to my own argument.