Ecological cultivation is a promising regime for medicinal plant production. For a long time, unreasonable farming methods have threatened soil health and medicinal agriculture and restricted the sustainable development of ecological agriculture for medicinal plants. However, there is a lack of comprehensive discourse and discussion about the pros and cons of different tillage regimes. Here, the research trend and application prospects of no-tillage (NT) are comprehensively reviewed, and the ecological benefits, challenges, and opportunities of the NT system in ecological agriculture of medicinal plants are scrutinized, aiming to call for an about-face in the sustainable conservation and utilization of both phytomedicine resources and agricultural/ecological resources. An exhaustive literature search in PubMed, Bing, Scopus, and CNKI was performed to outline the research trend in conservation tillage and medicinal plants during the recent four decades. The application of NT has a long history and can reduce tillage frequency and intensity and protect soil from erosion and deterioration. NT is often combined with organic mulch to significantly reduce soil disturbance. NT and stover mulching have the advantages of saving manpower and resources and improving soil quality, crop yield, and quality. The ecological and economic benefits of NT in long-term medicinal plant cultivation could be prominent. In developing medicinal plant cultivation, competing with food crops should be avoided as much as possible, and the impact on the production of major grain crops should be minimized. Therefore, the full utilization of soil resources in forests, mountains, and wasteland is advocated, and sustainable soil utilization is the core issue in the process of land reclamation. NT and stover mulching not only inherit the traditional concept of “natural farming”, conform to the basic laws of ecology, as well as the growth characteristics of medicinal plants, but also protect the ecological environment of the production area. It would become the core strategy of ecological agriculture for medicinal plants. Our summary and discussions would help propose countermeasures to popularize NT and organic mulch, promote relevant research and scientific allocation of resources, and adapt to local conditions to achieve precise management and harmonize conservation and production of medicinal plants.