Qiu Renzong1
SUMMARY The concept of global, Asian and Chinese bioethics are discussed in this paper and the difficulty in applying universal bioethics within different cultures and countries is addressed. The traditional beliefs and values in China are described with particular reference to medicine, and the implications for bioethics and research ethics within the country are considered.
Bioéthique : à la recherche de la diversité morale
RÉSUMÉ Le concept d’une bioéthique mondiale, asiatique et chinoise est discuté dans le présent article et la difficulté d’appliquer une bioéthique universelle dans des cultures et des pays différents y est abordée. Les croyances et valeurs traditionnelles en Chine sont décrites, notamment en ce qui concerne la médecine, et les implications pour la bioéthique et l’éthique de la recherche dans le pays sont examinées.
1Professor and Director, Programme in Bioethics, Institute of Philosophy/Centre for Applied Ethics, Chinese Academy of Social Sciences, Beijing, China (Correspondence to Qiu Renzong:
Moral unity or moral diversity?
The issue of moral unity or diversity arises from the fact that bioethics has expanded globally beyond Western countries. When bioethics was introduced in developed countries with a culture different from the Judeo–Christian culture in which bioethics was originally rooted, there arose a conflict or collision of cultures. But what has the result of this conflict or collision been? One conquers the other? Or the other closes its door and rejects everything? Is there a third way – for example, assimilating each other or seeking common ground while preserving the differences? In other words, what should we envision about bioethics within global development? Or what is the role of traditional values in the globalization of bioethics? Confucius would say “Junzi (an ideal person) is broadminded, but does not identify with others.” In other word, junzi will respect another person’s point of view and keep harmonious relationship with him, but will not accept the other person’s point of view as his own.
Knowledge is power. Modern technology is a great and fearful power. Wherever it invades, sometimes with weapons, sometimes with commodities, tradition seems to have to give way to it. It creates a new culture everywhere. Almost all countries with traditional cultures, after defeat by the imperialist powers and failure in resistance, tried to modernize. They tried to introduce, apply and develop modern technology within their own country. However, this in turn has caused a conflict between tradition and modernity, or between traditional values and modern values. When two cultures meet, the two do not simply merge into one, nor is each kept completely intact. Neither a traditionalist attitude nor a radically reformist one is appropriate or desirable.
The situation in China
In China, we have traditionalism. Examples of the traditionalist attitude include the Qing dynasty government, which dismantled the railway near Beijing because they worried about the impact of modern technology on the Chinese people, and also the Boxer movement when the people used gongfu to fight against the Western armies. But the efforts to keep Chinese tradition unchanged and to reject modern values failed. The opposite attitude is what we call radical reformism. Such advocates shouted the slogan “Down with Confucianism.” Should the traditional Chinese culture with its core of Confucianism be relegated to historical museums or the rubbish heap?
The question raised in recent waves of reform is – can traditional values play an important or even indispensable role in the era of modern science and technology in the 21st century or even the third millennium? The fact is we must consider the traditional values and sometimes when applying modern technology, these values should be taken into account. If we neglect some basic traditional values, we may have to pay a high price. The following examples illustrate this point.
Donor insemination in Shanghai
Shanghai is a modern city in China, perhaps the most modern. A young couple in Shanghai had been married for many years without a child. They went to see a professor who was an expert in infertility. The husband was diagnosed as being unable to ejaculate. The professor provided donor insemination to him and his wife gave birth to a boy and they were very joyful. However, when the couple brought the child home, because they lived within the extended family with three generations living together, the husband’s parents thought that the child did not look their son. The son had not told his family the truth and had simply said his illness was cured. They did not say that they had used the technology of donor insemination. After disclosure of this information, the husband’s family rejected the child because the boy did not have blood ties with the husband. The wife had to return to her mother’s house with her child. She sued the family in court, but the husband said that he had not known the truth and wanted to divorce her.
Cornea transplantation in Beijing
On October 13, 1998 when Dr G of the department of ophthalmology, hospital R in Beijing prepared to operate the next day, he found that the stored corneas were necrotic. He went to the hospital mortuary and removed two eyes from a dead female patient. After that he performed cornea transplantation for two patients and both of them recovered their sight. But at the crematory, the family of the dead woman discovered her eyes missing. It is very important in China to keep the body intact before cremation and so the family sued Dr G for half a million Chinese dollars (RMB) compensation. However, the state prosecuting attorney (who is responsible for formally accusing suspects in the public interest) decided not to sue Dr G.
Long-term care in Hong Kong
Following the British model, long-term care for the elderly in Hong Kong is covered by the Government and provided by public healthcare institution. But Hong Kong residents protested against this and claimed that care should be provided by their family members. In practice, a compromise between them needs to be reached.
Commercialization of medical care
We are paying the cost for turning the art of ren (humanness/humaneness) in to the art of making money. Twenty years of market-oriented reform have been deemed “basically unsuccessful” and have led to unfairness and low efficiency in healthcare. Ninety per cent of the population is very dissatisfied with the healthcare provided and 60% of medical costs are personal out-of-pocket payments [1]. Before the health care reform that was launched 20 years ago, the main provider of health care was the Government. Coverage shrank to 43% in cities and 3.1% in villages in 2003 from 70.9% and 5.8% in 1999 [1]. The percentage of healthcare expenditure was more than 5% of GDP, but almost 50% of outpatients and 30% inpatients did not go to hospital because it was unaffordable [2]. The population in China is increasing but the numbers of outpatients and inpatients are decreasing. So there is clearly injustice and efficiency.
This practice goes against the commandments of the ancient doctors. For example, Liu Fang said, “Before treating patients, we should treat our hearts first.” And an ancient anonymous author wrote, “The Tao of practising medicine is first to rectify ourselves and then properly use the medicine.” When a disciple came to the ancient doctor Li Gao to learn medicine from him, he asked the young man, “Do you want to learn to be a physician looking for money or to be a physician disseminating the Tao?” Xu Dachun in his article “On ginseng” criticized those physicians who used ginseng to treat patients and were both killing the patients and plunging their families into bankruptcy [3]. He says, “It was unforgivable for a physician to kill a patient with the improper use of a drug, but his deeds of killing a patient and plunging his/her family into bankruptcy were more vicious than what a robber or a thief did.” In the present times, there are many places in China where physicians are killing their patients and bankrupting their families.
How are global bioethics and Asian bioethics possible?
Since 1990 there has been a lot of controversial discussion on global bioethics and more recently there has been discourse on Asian bioethics. My question is, how is global bioethics or Asian bioethics possible? The argument in favour of global bioethics are the following: i) to provide common moral grounds for the international community to be able to take action; ii) by nature humans are alike; iii) ethical relativism is wrong; and iv) different values, different cultures or different moral communities will converge with social, economic, political and cultural change. There are four counter arguments. First, common moral ground can be reached by sharing values and negotiation, not necessarily by creating global bioethics. Second, Confucius said, “By nature men are alike, through practices they have become far apart.” Third, the fact that ethical relativism is wrong does not automatically justify global bioethics. Fourth, change does not necessarily lead to moral unity; moral diversity still exists.
The arguments against global bioethics include: i) human beings are embedded in different groups, communities and cultures; ii) morality or the ethics of different moral communities or cultures is somehow incommensurable even though they share similar values; and iii) global bioethics may lead to concerns about ethical imperialism.
Some bioethicists have raised questions and provided arguments regarding global bioethics. For example, Tangwa from Cameroon asks, “How is global bioethics possible in a world inhabited by different cultural groups whose material situation, power, ideas, experiences and attitudes differ quite markedly and who are not, in any case, equally represented in globalization efforts and forums?” Benatar from South Africa argues that imperialism is not only a political force which existed during the age of the British Empire, but that it is an ongoing feature of hegemonic world views, civilizations and religions. British bioethicist, Alistair Campbell, wonders whether global bioethics is a dream or a nightmare? Is it a nightmare of a homogenized lowest common denominator ethics? Or, worse, of the cultural domination of world bioethics by one set of moral assumptions and style of reasoning? Even if the term global bioethics can be accepted, it has to be based on a respect for the richness of human cultures and the fragility of the physical and social environments that sustain human life.
Just as there is no single global bioethics, there is also no single Asian bioethics. Asia is a continent with the richest cultures. Cultures from all other parts of the world can be found in this continent—Islamism, Hinduism, Buddhism, Confucianism, Taoism, Judaism, Christianity, and many aboriginal cultures. There are many different approaches, perspectives or paradigms of bioethics in Asia, but no single Asian bioethics. Even in China, there is no single Chinese bioethics. We have different approaches too, although we share some values among them.
The conclusion we can reach is that there are some shared values between Western and Asian approaches to bioethics and among Asian approaches. We share very basic values such as beneficence, non-maleficence, respect and justice. We can find these values in Confucianism. All these values could be put in the framework of Confucianism and I will discuss this later. These shared values constitute common ground for common action in this small world. But these shared values are inadequate to constitute an overarching ethical theory that can be called universal ethics or global bioethics or Asian bioethics. Both ethical universalism and ethical relativism are undesirable because they would lead to worries about ethical imperialism and ethical barbarism respectively.
Bioethics and research ethics in Chinese culture
Chinese culture has no tradition of human experimentation. After resisting it for many years, China has now accepted it and regulates it. However, some traditional values persist. Bioethics or research ethics have to be adapted to them, and it may in fact benefit them.
Traditional Chinese medicine is based on the theory of the yin-yang and wu xing. Chinese medicine is holistic with a concept of web of causation in contrast to the Western idea of single linear causation. Modern medicine is based on the theory of atoms, molecules, reductionism, dualism and linear causation. So it may be difficult when we go to the countryside to talk about the research of genetics or some such. It is difficult for a patient/subject to comprehend what atoms or molecules are whereas it is easy for him/her to understand yin-yang and wu xing.
Chinese cosmos
According to Chinese cosmology, the universe and all of its inhabitants are composed of qi. Qi is a physico–psychological entity, with the capacity for creation, change and transformation, which has two basic forms, yin and yang. The generation, change and transformation of all things are produced by their interaction, their being yin and yang interaction. The universe and its inhabitants are uncreated and are rather participants in an organic whole that interacts in a self-generating cosmos. There is no ultimate cause, no creator, no external will or judge. The universe has always existed – there has never been a time when it did not exist – and therefore the question of a creative act simply could not logically arise.
Confucian ethics
Confucian ethics emphasize virtue, duty and context, whereas the Western counterpart of ethics focuses on norms, rights and principles. In China, ethics are entrenched in general philosophy and culture. The core of Chinese culture is three teachings; Confucianism, Taoism and Buddhism, this of course, is Chinese Buddhism. Chinese philosophy is distinguished by its commitment to the human condition with a deep engagement in society and politics and a strong focus on practical insights. Chinese philosophy has four key theses:
- Sage within and king without. That is everybody can be a sage or Buddha, an ideal person. A sage’s virtues should be manifested in his actions and relationship with others.
- nity of nature and humankind. An ideal person would reach such a spiritual level where humans and nature are united as one. The care is for non-human animals and ecology as well as for humans.
- Seeking the truth from within. The Tao of nature and the Tao of humans are the same. If we develop our own character to the acme of perfection, we can know the truth of the external world. The only barrier to prevent us from knowing nature is our own selfish desires. This is why traditionally in China we did not develop experimentation, including human experimentation, because the Chinese epistemology was different.
- Reason and emotion are inseparable. Emotion can help reason. So in China we believe in making people understand the reason or principle, while moving them with affection.
Chinese traditional epistemology is an introspectionist approach, which says that if the mind is stable, you will be able to see and hear clearly, your limbs will be strong, qi will be kept in your body. Guan Zi, a Taoist, said that if the mind is stable, the world will listen to you. Hui Neng, a Zen master, said, “Perfect wisdom is inherent in all people. It is only because they are deluded in their minds that they cannot attain enlightenment by themselves. Calmness and wisdom are foundations of my method.” So they are introspectionist in the theory of knowledge. It follows from introspectionism that observation and experiment are not indispensable to obtain knowledge.
Chinese medicine – the art of ren
Confucian physicians argue that medicine is the art of ren (humanness/humaneness), which requires rectifying yourself before treating patients and helping or doing good to patients. Confucian physicians argue that physicians should do good to as many people as possible, which includes parents, king and ordinary people, and treating patients equally. The last but not least is the belief in pursuing the Tao of medicine instead of the profits. Ren therefore requires overcoming ourselves (keji).
In China there is a very close relationship between Confucianism and medicine. Confucian medicine is the mainstream of traditional Chinese medicine. It promotes medicine more than other philosophies. It values human life and health highly, emphasizes care for others and only pays attention to this life, not the next. Medicine became an application of Confucianism in the field of healing art. Medicine is an essential part of Confucianism. Mastering medical knowledge is one of the requirements for practising ren. But what is the meaning of ren? This is a very crucial concept in Confucianism. Ren is love, compassion and care for others, the sentiment embodying regard for others and moral capacity to feel for others. We love others and are compassionate to others not because we benefit from it, but because we have the heart that cannot bear the suffering of others. Mencius said, “When we suddenly see a child about to fall into a well, we will have the feeling of alarm and compassion. This is not because we want to enter into good relations with the parents of the child, or because we want to gain praise from his neighbours and among our fellow colleagues and friends, or because we dislike the cry of the child, but because we have the heart which cannot bear the suffering others.”
Ren is the extension of natural compassion that everyone feels in view of the hardships and misfortune of others. Ren can be and has to be cultivated and developed in interpersonal or social relationship, first within family. The method of actualizing ren is from near to far. Actualizing ren begins with family. Xiao, filial piety towards parents and ti, fraternity towards brothers/sisters are the roots of ren. Confucius said, “If a man cannot even reciprocate the intimate human affection experienced within the family bond, it is not likely that the development of the person can be achieved in the less intimate environment outside the family circle.” The affection that is assumed to grow naturally in family should become the model for treating others in general, in society, including non-human animals. Mencius said, “I have no heart to eat the meat hearing its cry.”
Thus filial piety is a very important value in Confucianism. The requirements of xiao include the study medicine in order to care for parents. Xiao in traditional interpretation also includes the requirement to keep the body intact. The body, including our hair and skin, are received from our parents. “We dare not cause any injury to it and this is the beginning of filial piety”, is one of the Confucian classics in the Book of filial piety. Another requirement of xiao is extending the life of ancestors. Mencius said, “There are three things that are not filial and to have no posterity is the greatest of them.”
Ren should be cultivated in a physician’s heart. Confucius said, “If there is no ren in one’s heart, how useful is li (norms) for her/him?” The relationship between physician and patient is more than the one between provider and client. It should be a fiduciary relationship.
Chinese concept of personhood
Another very important concept is that of personhood, the relational concept of personhood. A person cannot be reduced to a set of human genes or human genome, as genetic essentialism claims. Even self-consciousness is not a sufficient condition. For an entity to become a person, it has to be in an interpersonal and social relationship. Even consciousness or self-consciousness is shaped within this relationship, not outside it. So according to Confucianism, a person begins with birth. Also according to Confucianism, a person is not independent, but rather is in an interdependent relationship with others, first parents and family members. Family thus plays an indispensable role in clinical decisions in the Chinese cultural context. There are two consequences of this concept. First, a person’s individual interests must be balanced with the interests others. A person’s individual rights have to be balanced with his obligations or responsibilities. The Confucian relational concept of personhood implies that the self is enlarged to self-in-relationship. The individual and others are interrelated and interdependent.
Chinese concept of rights
According to Confucianism, a person is a role player. When a person becomes competent, he or she has to act responsibly. It is in one’s role relationship and role performance that one finds the source of one’s value and dignity as a person and the basis of one’s self-esteem, worth and fulfillment. Personhood is an achievement, rather than a given right or a right of birth. Consideration of rights is very useful in some cases but ethical dilemmas cannot be solved merely by this. Many rights are in conflict not only with different individuals but also within the same person. Exercise of rights depends on context. The rights approach focuses on which rights a person should enjoy, but is not concerned about whether a family or community has sufficient resources available to meet the needs of all individuals when exercising their own rights, and who is obliged to provide the necessary means to allow these rights to be exercised. The rights approach does not consider the human finitude.
Implications for bioethics and research ethics in China
The Chinese belief is that human life begins with birth, not the instance when the sperm penetrates the ovum; thus a human embryo or fetus has not become a person yet, although they should enjoy certain respect, such as that afforded a human corpse. Abortion becomes a moral issue only in so far as it brings harm to a pregnant women rather than because it kills a fetus. Thus, embryo research or deriving stem cells from an embryo per se are not ethically problematic.
The technologies, such as artificial insemination by husband, in vitro fertilization, intracytoplasmic sperm injection and surrogate motherhood are acceptable in general but donor insemination is rejected in some traditional families as the case described earlier demonstrated. What about brain death and euthanasia? The meaning of human life is not mere existence but living in a way that benefits others. The heart is the central organ of the body. There is a strong affective or emotional tie between those who are irreversibly comatose and terminally ill with intractable pain and their kin. China is the only country that has not accepted brain death as legal yet, and euthanasia is illegal too. Organ and body are given by parents and it is not permitted to donate them even after death. Even when the dead body is eventually sent to the crematorium, it should be kept intact. There are only two exceptions to this: meeting a parent’s need or sacrificing for practising ren when the nation is in a crisis. Health and disease are not an individual problem but a family one. The family plays an indispensable role in clinical decisions. Clinical decision is usually not a patient’s individual decision, rather a family decision incorporating the patient’s views. In sexist, poor families, women/girls are the lowest priority. So there is no mechanism to protect a vulnerable member in a traditional family. For example, a Chinese–American female patient was admitted to hospital in the US. When her doctor disclosed the medical information to her, she refused to listen and instead asked him to tell her husband and obtain consent from him
Human experimentation
Human experimentation violates the principle of xiao, filial piety; this is an ethical barrier in traditional Chinese culture. Human experimentation is not necessary because of the introspectionist approach to the theory of knowledge. It is an epistemological barrier. In addition, there is an aversion to human research or experimentation for historical reasons, in particular the inhuman experiments conducted by the Japanese 731 unit. There is also a barrier to informed consent. Because Western and Chinese people live in a different cosmos and speak different languages, so the information provided by one side is difficult to be understood by the other side; and the family has to play some role in the process of consent. But what kind of role should the family play? Furthermore, some Chinese in rural areas are reluctant to sign the informed consent form. They worry about what could ensue after signing? Peasants in rural areas have bad experiences with signing; for example, in some instances they have found that after they signed a contract, their ox or cow was taken away by their landlord.
Family-assisted informed consent
Zhai, in her unpublished pilot survey, reported that interviewees supported the view that respect for a person should include respect for the person’s culture, because culture is part of a person. Therefore in China, consent is not merely an individual’s prerogative or responsibility. It is associated with the wider obligations to family. Family members have a responsibility to assist their diseased kin in decision-
making, whether it is participation in a clinical trial or not. We call this model family-assisted informed consent. Most people in her interviews thought that consent assisted by family members rather than consent by the individual alone was more valid, given the culture and situation in China. For their part, participants would like to take time to discuss the information with their family members before they make the final decision. Furthermore, the Chinese did not accept the terms “research” or “experiment”, but would only accept “observation of medicine’s effect”. In rural areas, the consent of women was obtained after their negotiation with their family, their husband and/or mother-in-law in particular. In some cases, the village doctor signed the consent form because the subjects did not want to sign the form even though they consented to participation in the project [4].
Family in today’s China
We have had 20 years’ experience of health care reform in China during which the status of the family has changed. Tao and her Hong Kong colleagues conducted a survey in mainland China [5]. The findings indicated that the Chinese interviewed did not support the isolated nuclear family thesis as an inevitable outcome of industrialization and modernization. However, this did not imply that the Chinese family in the transitional economy had not undergone some adaptation to respond to the new social environment. Their conclusion was that the family is still highly treasured in Chinese society, even in the age of economic reform and rapid social changes. This is because the Chinese family embodies the value of mutual care, reciprocal support and human connectedness, which are values deeply engrained in the Chinese mind. As a rule, in the clinical context, a decision is made by the family including the patient him/herself but not the patient alone.
Bioethics in China: the future
Now what is the future? Bioethics/research ethics with its principles and practices will further develop in China but they should be interpreted within the Confucian framework and coloured with characteristics of the native culture. Some traditional values will be abandoned, some reinterpreted or refined, some assimilated into practices or regulations and even adapted by other cultures. So ultimately bioethics/research ethics in China will incorporate features of our own culture.
References
- Health news, 1 July, 2005 (Ministry of Health, China).
- Health news, 11 January, 2005 (Ministry of Health, China).
- Shanghai College of Traditional Medicine: selection of ancient medical texts. Shanghai, Shanghai Press of Science and Technology, 1980:228–9.
- Qiu RZ. Tension between modern values and Chinese culture. In: Bankowski Z, Levine RJ, eds. Ethics and research on human subjects: international guidelines. Geneva, Council for International Organizations of Medical Sciences, 1993.
- Tao J, Chen Ho Mun. Chinese family and Chinese women in the transitional economy. In: Qiu RZ, ed. Feminist philosophy and public policy. Beijing: Chinese Social Sciences Press, 2004.
