Ole Döring Intercultural Issues of Medical Ethics in China 1
Ole Döring Intercultural issues of Medical Ethics in China 1
(in Karl-Heinz Pohl and Anselm W. Müller (eds.), Chinese Ethics in a Global Context. Moral Bases of Contemporary Societies, Leiden and Boston (Brill)2002: 349-372)
Intercultural issues of Medical Ethics in China
(Ole Döring)
1 Introduction
This paper attempts to acquaint an international audience with the state of Medical Ethics in China, with a special focus on its international and cultural significance. As other contributions in this volume have explored major philosophical issues at length, it may be appropriate now to address some rather concrete ethical questions; hence I approach the ethical issues in a sense from the 'bottom', namely from a perspective of practice. The following sections will introduce an outline of the current state of Medical Ethics in China[1], followed by a review of the emergence and some main issues of this topic. I shall touch a number of problems, without room for exploring them in detail. This mostly descriptive and multi-disciplinary paper does not attempt more than to 'add some flesh to the bones', which might provide useful information for the ongoing discussion. After a short reflection of its cultural impact I shall close my observations with an even briefer philosophical view on Medical Ethics in China.
2 A Hermeneutic Remark
Why am I not discussing 'Chinese Medical Ethics', as we are accomodated to such topics as 'Chinese Philosophy' or 'Chinese Arts'? The simple answer is that I do not feel comfortable about the implicit logic of this attribution. 'Chinese Medical Ethics' allows for two different interpretations. The first reading merely describes that either the actors or the locations of Medical Ethics are identified as 'Chinese', just as in 'Chinese Genetics'. The second interpretation additionally ascribes certain specific features to Medical Ethics, namely that there is a substantial point in characterizing Medical Ethics as somehow 'being Chinese'. This reading suggests that there is a particular stile, a set of methods or even a unique discipline expressed by the 'Chineseness', that originally to be located in China, or in Chinese culture, respectively, in a normative sense.
It is obviously not helpful to use such a conceptual framework as a starting point in an international context, because it reduces our conceptual kit and excludes major dimensions from the ethical debate. Also the objection against the confusion of the historical fact that an ethics has been developed under certain circumstances with ethical arguments as being the culturalistic mode of the natural fallacy applies here[2]. Moreover, at least in German and English languages, there are some unfortunate pejorative connotations in the attribution of something as being 'Chinese'. It still bears connotations of some strange and alien oddity, which makes it particularly problematic in the normative context of Ethics to establish the common ground of taking all sides serious. If we, on the other hand, accept the first interpretation as being less biased and leaving room for all justifiable applications, we are best advised to cling to the plain phrase 'Medical Ethics in China'. This phrase is clear, unbiased and leaves it a matter of scientific discussion and evidence which of the respective approaches to support. If we find a substantially original approach to Medical Ethics in China, this will be highly appreciated, still it would have to be explained, if and how this approach is sufficiently and convimcingly represented by a term as plentiful in connotations as 'Chinese'. The burden of proof, however, rests on the pre-occupied, exclusive and reductionist usage of 'Chinese Medical Ethics'. Hence, just as we do not talk about 'American' or 'European Bioethics' in a substantial sense, but distinguish between different methodological or normative approaches, both within and transgressing the geographical borderlines, I suggest to maintain the phrase Medical Ethics in China.
3 An Outline of Current Medical Ethics in China
Medical Ethics in China is an integral part of the debates in the field of Bioethics. I am using the word ethics with its specifications here not in the older sense of normative debates among certain professional ingroups, but in its comprehensive but probably more vague sense, namely as a general discourse, involving diverse disciplines, views and interests, for which, figuratively speaking, only 'the Sky is the Limit'. In this sense[3], Medical Ethics in China is more or less strongly articulated with a new-fashioned emphasize on practical normative problems of our transforming, highly industrialized and high-tech globalizing world, with clusters of social issues included. Thus its focus is shifted from more conventionally or ideologically confined forms of ethics towards an international and scientific state of the art. As it is explained by Yao Jiehou in this volume, the emerging ethical debate in China entails new forms, such as business and management ethics, gender ethics, and ethics of human genetics, and others more. Right now, further issues of ethical concern are expressed, organizational and structural problems are being approached and discussed in numerous locations all over the vast country. The mainstream of Bioethics, however, is made up by transformed and diversified, but still common fields of Bioethics, such as Applied Ethics, Environmental Ethics, and last, but not least, Medical Ethics. The debate is vivid and dynamic, its practical prospects exciting but unclear.
In fact, as regards the number of voices raised and the quantity of statements produced, discussions of Medical Ethics apparently have taken the lead in Bioethics in China, in some fields they constitute an avantgarde of scientific ethics. Among the main reasons for this prominent status are: medical issues are composed of everyday's matters and intuitions concerning health, life and death; they evoke a common association of high technology with some science fiction appeal, that meets smoothly with the utopian discourses Whalen Lai addresses in this volume; they further correspond with a general positive attitude towards matters of an international flair; moreover they are fueled by a particular scientific excellence among the medical and high-tech scientists; and, not to forget, they are propelled by the rich biomaterial ressources, and an overwhelming demand for Medical Ethics amongst policy makers and in the population. These are some mainly sociological and psychological factors. One more factor is the political liberalization which encourages the quest for new social and behavioural concepts and guidelines. I will come to the more philosophical aspects later. Putting it briefly: while, on the one hand, Medical Ethics in China is booming, as a result of the great demand and scientific excellence, we have to be reminded of a general absence of a related spiritual or philosophical groundwork.
The fact of such a fundamental lack notwithstanding, the very number and variety of approaches to Medical Ethics in China with at least some philosophical significance calls for closer observation. I shall now very briefly outline three of the more outstanding patterns of Medical Ethics I have identified within Chinese writings and discussions on several occasions[4]:
Firstly, there is a pattern of an original Chinese philosophy which deliberately does not restrict itself to the sources of the traditional canon. Instead, it attempts to develop a 'Chinese perspective' as a contribution to the global debates, that is often labelled as a branch of Confucianism. This approach has one of its most ambitious proponents in the person of Lee Shui-chuen (Li Ruiquan) from, Taiwan, who is following the teachings of the late Mou Zongsan. But it is as well shared by Taiwanese Buddhists who are experiencing their own success story on the field of Bioethics, and by Daoists and others. Far from seeing themselves as advocates of a relativistic ethics, they try to support a philosophia perennis. This emerging school is struggling with some internal theoretical contradictions, one of them creating a tension between claims of a 'Chinese substance' and the universalistic ethical intentions advocated[5]. However, the colleagues around Lee are seriously determined to promote a better ethical understanding of medical and health care issues on a basis of an original Chinese cultural and social consciousness, together with a focus on international integration.
Secondly, among these three patterns, there is a faction which can be identified as an approach of Practical Wisdom. This approach is less interested in creating ethical models of theoretical accuracy or lofty metaphysical speculations. Its focus, however, grounds on decent scholarship and is concerned with sound practical guidelines, strategies and measures which would efficiently and justly enhance the standards of health care, medical sciences and medical services, and which would solve the material and infrastructural problems in supply, distribution and allocation of resources, skills and facilities in the developing PRC.
Their explicit chief goal is to help the ordinary people according to the concept of humaneness (ren). Following a practical imperative, they try to become engaged in the respective political, administrative and legal procedures. Sociologically speaking, with fellows from the human, natural and social sciences, accompanied by administrators, health care workers and others, this fraction is the most interdisciplinary and multifaceted among the branches of Medical Ethics in current China. It is, at the same time, also the politically most exposed and endangered branch of Medical Ethics in China. The most eminent representative of this 'Practical Wisdom' approach is the philosopher Qiu Renzong from the Chinese Academy of Social Sciences in Beijing.
In accord with the 'Practical Wisdom' is an approach of a 'Pragmatic Social Ethics'. This particular subdivision is concerned with even more concrete and narrow aspects of issues such as normative standards for distributional justice in the health care system of a clearly defined social community, such as Hong Kong.
The third pattern of Medical Ethics in current China may be called the Connectedness approach. In terms of academic installment, this is a rather recent and immature, though exciting approach, especially from an interculturally interested view. It has been put forward by scholars somewhat out of the academic mainstream, like Ip Po-keung, Anthony Fung and Julia Tao from Hongkong. They are exploring the normative impact of 'Connectedness' in cases of the practice of Medical Ethics. Although 'Connectedness' is rather a descriptive category, these scholars give it some credit for overcoming the arbitrary dualism of antagonistic normative concepts, like 'Individualism' versus 'Collectivism', in many discussions of Medical Ethics. The starting point is the intuition of ethical duties and rights as intrinsicly reciprocal. Hence this approach attempts to nullify the one-sidedness of collectively versus individually grounded ethical claims. At the same time, 'Connectedness' is offered as a conceptual catalyst to accomodate essential concepts of both, classical Liberalism and Confucianism.
What is more, this term has not been discredited by ideological instrumentalization yet, as it has been the case with 'Communitarianism', or 'Embeddedness', or 'Liberalism'. A presumptive merit of this approach lies in its prospect of systematically charting the interplay of objective and subjective interests and aspects of medicine and health care. As the authors claim, this enlarges the scope of Medical Ethics beyond formal professional or legal competences, and opens the door to humaneness in medicine (for instance by methodically involving people with a subjective but immediate personal 'connection' to an incompetent terminal patient in cases of decisions concerning his or her will).
I would like to emphasize that this very brief sketch of three main patterns is just a preliminary suggestion, that leaves aside many interesting approaches to Medical Ethics emerging in China these years. And it goes without saying that a large fraction of Chinese Medical Ethicists are discussing ethical works written by colleagues with an international background just on a common (not just 'Western') academical basis. I do not give much credit to the assumption that involving themselves into the international debates makes our Chinese colleagues somewhat 'less Chinese'. Actually, some of the Chinese discussions of their 'Western' colleagues' theories make up original substantive contributions which right now mould what is going to be called the Chinese position in the near future. It is sad to say, but true, that these approaches still often remain unheard and unanswered in international ethical circles, due to the ignorance of many 'Western' colleagues. If we could achieve a stage of greater mutual commitment to Medical Ethics internationally, this would help to let our attention focus on a freshly inspiring perspective on arguments and ethical systematics in their own right, instead of being pre-occupied with cultural or traditional backgrounds of authors before reading their arguments.[6]
Now I would like to go back to the current profile of Medical Ethics in China as it is primarily shaped by medical and other bio-scientists.
4 Main issues and activities of Medical Ethics in China
Traditional medicine in China has a history of at least two thousand years. It is a general assumption in current debates that Confucian physicians of the ancient and medieval times have written articles on medical ethics, so that a traditional background for Medical Ethics in China can be provided for. Accordingly, medicine is explained as an Art of Ren (humaneness) which requires the physician to
1. Having ren in the heart;
2. Treating the patient benevolently;
3. Treating patients equally; and
4. Not pursuing profits.[7]
4.1 The emergence of current Medical Ethics in China
Since the 1980s, Medical Ethics has become a topic of increasing interest among bio-scientists in China. This development has been encouraged by some favourable social and intellectual factors, such as, firstly, a widespread appreciation of technology and a pragmatic attitude to build up and apply high-tech in health care and other medically relevant fields; secondly, an increasing prosperity and relative social stability in some Chinese regions; thirdly, a new tolerance of pluralism of values and beliefs; and, fourthly, a visible decline of conventional paternalism in medicine and society, at least in the advanced regions.
The growing interest is reflected by new activities in publication since 1980. In 1980, two journals have begun to publish articles on Medical Ethics, that is Yixue yu Zhexue (Medicine and Philosophy) in Dalian, and Zhongguo Yixue Lunlixue (Chinese Medical Ethics) in Xi'an. Articles on Medical Ethics are also published in the journals Ziran Bianzhengfa Tongxun (Journal of Dialectics of Nature) and Ziran Bianzhengfa Yanjiu (Studies in Dialectics of Nature). In the Fall of 1995, the first issue of the Zhonghua Shengming Lunlixue Tongxun (Chinese Bioethics Newsletter) was released, parallel in Beijing and Hongkong. Another series title is the Ethics and Society Newsletter, published by the Center for Applied Ethics at the Baptist University at Hong Kong, appearing since 1993, with a diversified range of Bioethical issues, including Medical Ethics. In Taiwan, following recent activities in the field of ethics, philosophers of the Chungli University are releasing a Yingyong Lunli Yanjiu Tongxun (Newsletter for Research of Applied Ethics) since early 1997. The Center for Applied Ethics at the Chinese Academy of Social Sciences (CASS) in Beijing has published the first issue of its Tongxun (Newsletter) in April 1998. And, most recently, the Journal Zhong Wai Yixue Zhexue (Chinese and International Philosophy of Medicine) was instituted in 1998 to facilitate the dialogue between Chinese and International Medical Ethicists.
The name of the last, but certainly not the least important periodical of significant influence on the Chinese debate, I would like to refer to here, is the Eubios Journal of Asian and International Bioethics which is distributed in both, paper and internet website[8] form, in Japan, now in its ninth year, since 1991. This journal is the most widespread source of up to date information and a lively discussion forum for all aspects of Bioethics in East Asia, with a high portion dedicated to Medical Ethics. Since 1997, the EJAIB is the official organ of the Asian Bioethics Association.
Among the various titles of more general interest one outstanding book and its author shall not be left unmentioned here. In 1987, the first and pathbreaking Chinese monograpy about 'Bioethics', with an intended audience of physicians, bio-scientists and interested academics from various disciplines, was published in Shanghai[9]. Its first 50.000 copies have long been sold out on the mainland, and an enlarged, revised second edition is in the pipeline. 'Bioethics' was reprinted in 1988 with the title 'Between Life and Death: Bioethics and Moral Dilemmas' in Hong Kong and Taiwan[10]. The author, the well-known philosopher Qiu Renzong from Beijing is at the same time the most active Chinese mainlander recognized in international dicussions of Medical Ethics. His chair at the CASS Institute of Philosophy offers the only postgraduate academic degree in Bioethics in China.
4.2 Education of Medical Ethics in Medical Universities
As a developing country, China has lagged behind developed countries in the introduction of Medical Ethics as part of the training of health care professionals. In 1980, a group of scholars at the Shanghai Second Medical University, which is one of the leading Chinese Key Universities, reconsidered its teaching programme. In an attempt to reform the curriculum for medical students it was recognized that Medical Ethics, as an interdisciplinary field between medical sciences, ethics and social sciences, should be regarded as a priority. Experience from everyday's medical practice has urged professors and administrators to set up rules and guidelines for regular procedures and proper medical conduct, which should be observed by both, medical professionals and patients.[11] The new slogan is now that China, just as every advanced society, needs such practical norms, in order to guarantee fairness, justice, and contained development in all fields of medicine under the new conditions of a modernizing and fractionizing society. Today most of the Key Medical Universities in China are offering courses in Medical Ethics with medically and ethically approved teaching programmes. It is mandatory for each medical school to provide and require "Medical Ethics" courses for medical students. In some medical schools the MA degree on Medical Ethics can be conferred to graduate students. Institutional Review Boards and Ethical Committees have been set up in some hospitals. The Chinese Society for Medical Ethics has been founded and affiliated with the Chinese Medical Association. It organizes national meetings, and it is an institutional member of the International Association of Bioethics, with the corresponding high prestige.[12]