Medical Ethics in China

A Transcultural Interpretation

Jing-Bao Nie

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9780415724562
• eBook ISBN: 9781136491245
• Edition: 1
• Topic: Law
• Subtopic: Comparative Law
• Index: Law

Drawing on a wide range of primary historical and sociological sources and employing sharp philosophical analysis, this book investigates medical ethics from a Chinese-Western comparative perspective. In doing so, it offers a fascinating exploration of both cultural differences and commonalities exhibited by China and the West in medicine and medical ethics.

The book carefully examines a number of key bioethical issues in the Chinese socio-cultural context including: attitudes toward foetuses; disclosure of information by medical professionals; informed consent; professional medical ethics; health promotion; feminist bioethics; and human rights.

It not only provides insights into Chinese perspectives, but also sheds light on the appropriate methods for comparative cultural and ethical studies. Through his pioneering study, Jing-Bao Nie has put forward a theory of "trans-cultural bioethics, " an ethical paradigm which upholds the primacy of morality whilst resisting cultural stereotypes, and appreciating the internal plurality, richness, dynamism and openness of medical ethics in any culture.

Medical Ethics in China will be of particular interest to students and academics in the fields of Medical Law, Bioethics, Medical Ethics, Cross-Cultural Ethics as well as Chinese/Asian Studies and Comparative Cross-Cultural Studies.

Part I

Beyond stereotypes
and stereotyping

Chapter 1

Communitarian China versus
the individualistic West

A popular myth and its roots

Since British poet Rudyard Kipling penned his famous lines, “Oh, East is East and West is West, and never the twain shall meet,” in “The Ballad of East and West” (1895), the world has moved on. Whether people like it or not, the twain came together a long time ago. However, the mentality behind Kipling's words stubbornly refuses to go away. Deeply rooted stereotypes and myths die hard in bioethics, as in the public mind.

The most persistent and widespread myth sets up a static, homogeneous, and monolithic Chinese culture in radical contrast to a fluid and pluralistic Western culture—in its simplest and most popular version, a collectivist, communitarian or familist China versus an individualistic West. This dichotomy has achieved almost universal currency and permeated all levels of discourse. Underlying this myth is an age-old and still dominant way of thinking about cultural differences as “radical others”: the dichotomizing of East and West, of “them” and “us.” Accordingly, both outside and inside China, a unified, single and communitarian Chinese medical ethics is widely believed to exist in radical opposition to a Western bioethics, perceived as individualistic in character and in practice.

In this and the following chapter, I offer a critical study of this myth and expose the intellectual fallacy and political perils of dichotomization. I will discuss its enormous popularity, modes of expressions and the main intellectual or epistemological root of the myth not only in the West but also in China. As next and other chapters in this book will show, this myth and the dichotomous way of thinking about Chinese-Western cultural differences have brought about a series of grave consequences. Among the gravest ones are that cross-cultural similarities and commonalities are overlooked and that the great internal diversity and pluralism of cultures and medical ethics within China has been minimized and denied.

Western attitudes: two opposing ideologies, one shared myth

In the West, two apparently opposing attitudes can be distinguished on the subject of cultural differences. The first is what can be called the “modernist” or ethnocentric way of thinking about cultures. The modernist approach to Occidental and Oriental cultures was vividly depicted by the German author Thomas Mann through the character of Herr Settembrini in The Magic Mountain. Settembrini, an inmate of a tuberculosis sanatorium in Switzerland, is the intellectual guide of Hans Castorp, the young, questing hero of the novel. According to the “Settembrinian cosmogony,” wrote Mann, two incompatible principles, one Asiatic and the other European,

were in perpetual conflict for possession of the world: force and justice, tyranny and freedom, superstition and knowledge; the law of permanence and the law of change, of ceaseless fermentation ensuing in progress. One might call the first the Asiatic, the second the European principle; for Europe was the theatre of rebellion, the sphere of intellectual discrimination and transforming activity, whereas the East embodied the conception of quiescence and immobility. There was no doubt as to which of the two would finally triumph: it would be the power of enlightenment, the power that made for rational advance and development.

(Mann 1969: 157)

For Settembrini, an Italian humanist zealot, the Asiatic principle has to be “crushed” for the sake of progress, science, and human reason. With “his suave smile,” he foresaw that, in fulfilling this task and other “sublime exertions,” the blessings of enlightenment would soon come to all of Europe and the whole of humankind, “if not on the wings of doves, then on the pinions of eagles” (Ibid).

This Eurocentric or chauvinist attitude was also manifested by the seventeenth-century Jesuit missionaries who were deeply disappointed to discover that the Chinese neither believed in God nor had any form of systematic logic; by the philosopher Hegel, who assumed that there was no real philosophy underpinning Chinese civilization; and by the scientist– philosopher Alfred Whitehead, who asserted that China had never made any progress in science and that the Chinese contribution to science was practically negligible.

A typically Western ethnocentric response to Chinese medical ethics was provoked by the earliest visit of Western bioethicists to China in 1979, just as the nation was launching its “revolutionary”—or “anti-revolutionary” according to Mao's ideology—state policy of “reform and openness.” Organized by the Kennedy Institute of Ethics (one of the leading programs in contemporary bioethics), a group of American bioethicists, along with lawyers, theologians, and physicians, travelled for two weeks throughout China. This visit provided American specialists with their first opportunity for a serious and explicit evaluation of contemporary Chinese medical ethics.

However, disappointment awaited them. Far from what they expected, they discovered that no “bioethics” existed in China in comparison with the U.S. The group's spokesperson, H. Tristram Engelhardt, Jr., later reported that “in the real sense there is no bioethics in the PRC as a scholarly subdiscipline,” and that the Chinese “failed to distinguish principles” from the “grounds” or “conceptual foundations” that justified those principles. The reasons Engelhardt gave for this absence of bioethical inquiry on the part of his Chinese hosts included “their lack of extended experience with a variety of moral viewpoints” and their “unfamiliarity with discussions focused primarily on discovering the comparative intellectual merits of varying moral viewpoints apart from any immediate concern to establish or maintain a single one.” Other reasons suggested for the absence of bioethics in China were that the prevailing ideology of dialectical materialism denied the importance of moral reflection and emphasized the determining role of the economy, and that China lacked a well-developed philosophical tradition of “criticism and debate about the intellectual bases of social and moral policies.” For the American team, their Chinese hosts “had their own positions, replete with implicit subtle distinctions. It is simply that they had not attended with a conceptual, analytical interest to the nature of those distinctions.” (Engelhardt 1980: 8, 10)

Over the past few decades, a new approach to cross-cultural differences—one that can be called “postmodernist” or relativist—has been unfolding. Countering the negative view of the East, the postmodernist standpoint takes a positive attitude toward non-Western cultures. One of the many historical forces that have contributed to this postmodern turn is the radical criticism of modernity and such modern values as rationalism, universalism, liberalism, and scientism. The postmodern approach to thinking about cultures rejects the habit of judging the values and norms of one cultural system—non-Western cultures in particular—from the standpoint of Western culture.

Curiously, this postmodernist—or even romanticist—attitude has modern roots, at least with reference to China. It reminds us of the sixteenth-century Italian traveler Marco Polo, who described the material prosperity and moral superiority of China in high-flown prose; the Enlightenment philosopher Voltaire, who portrayed China as the ideal model of rationality in his attack on Christianity and theology; and the great twentieth-century historian of science Joseph Needham who, with his collaborators, argued eloquently in his voluminous works that Chinese science and civilization, especially the unique philosophy of the organism, constitute a beacon to the rest of the world.

The first real evidence of a positive attitude to medical ethics in China in the contemporary West was seen in a very influential article published by two American sociologists–bioethicists, Renée Fox and Judith Swazey. In 1981, Fox and Swazey conducted six weeks of fieldwork in China, primarily at a Western-style urban hospital in Tianjin, a northern industrial city near Beijing. Unlike their counterparts at the Kennedy Institute of Ethics, they had set out for China with no plans to explore ethical issues in medicine.

Yet, on their return, the two sociologists brought back plentiful evidence of “medical morality”—the peculiar “form … taken by medical ethical interest and activity” in China. They charged Engelhardt and his colleagues with an “inadvertent ethnocentricity”—seeing China in the same way as the Jesuit missionaries had done. They attributed this disturbing “cultural myopia” to the general cultural perspective of the American bioethicists, leading them to “ignore or misperceive the social and cultural matrices of their ideas.” They told their readers:

It was both surprising and satisfying to learn in a first-hand way that, despite the thousands of geographical miles and historical years that separate Chinese society and our own, and their very different cosmic outlooks, these aspects of Chinese thought are compatible with the conceptual and methodological framework in which we observe, analyze, interpret, and evaluate as sociologists.”

(Fox and Swazey 1984: 339)

They were in no doubt as to the existence of a Chinese medical ethics—one that, among other virtues, emphasizes a spirit of self-sacrifice and self-cultivation, a lofty sense of responsibility, modesty, self-control and devotion to family and nation, and other virtues.

Moreover, Fox and Swazey argued that, although strange to American eyes, many aspects of Chinese “medical morality”—such as the emphasis on personal virtues, holism, “two-legged dualism” (which always involves a chain of dualities: yin-yang, self and others, the individual and society, being “Red” and being “expert,” preventive and curative medicine, modern Western and traditional Chinese medicine, and so forth), the principle of dynamic complementarity, pragmatism, and collectivism—could provide an effective antidote to many problems and deficiencies in American bioethics. At the same time, they criticized American bioethics and its intellectual assumptions with a series of observations on its narrowly gauged individualism, the dominance of rights language, its contractarian outlook, scientism, positivism, universalism, objectivism, materialism, rationalism, absolutism, secularism, and so on.

Indeed, the primary goal of Fox and Swazey was not so much to introduce their American audience to Chinese medical ethics as to use China as a comparative reference to analyze and illuminate the sociological characteristics of American bioethics—summed up in the phrase “rugged individualism.” Their real purpose behind commending Chinese medical morality was to offer a cultural critique of the “American-ness” of bioethics—their aim was to push American bioethicists to realize that “bioethics is not just bioethics, and is more than medical.” In this sense, their basic approach was American-centred, not China-centred. In fact, this emphasis—American-centred-ness—has been a leading feature of American scholarship on China, especially the American historiography of China (Cohen 2010 [1984]).

These two contrasting American responses to medical ethics in China occurred thirty years ago. One might expect that, as a result of the dramatic socio-historical changes during the period since, some significant advances would have been made in the West's understanding of culture(s) and medical ethics in China. It is true that, over the past three decades, China and the West have experienced unprecedented interactions, both large-scale and intimate; bioethics has evolved into a well-established and institutionalized though still rapidly expanding academic field; and medical ethics in China has also undergone great transformations. Unfortunately, however, there is no evidence to show that the general understanding in the West of medical ethics in China has been much advanced by comparison with the views expressed by these two groups of American academics.

Today, there is no doubt that people in the West know more “facts” about medical ethics in China. And there is an emerging body of English-language literature on the subject, as briefly reviewed in the introduction. But, the development of an adequate general understanding is another matter. Some academic investigators have changed their position. For example, Engelhardt, now one of the best-known Western bioethicists in China, has long shifted his allegiance to the postmodernist camp and argued against any possibility of a global bioethics (2006). He promotes the idea of an Asian or Chinese versus a Western bioethics both in his own writing as well as by encouraging his Asian and Chinese students and colleagues to pursue the route of a thoroughly dichotomized East and West (Nie 2007). The assumed radical differences between Western and Asian (or other non-Western) cultures provide strong empirical “evidence” for a key concept of Engelhardt's bioethical theory (1996), the notion that “moral strangers” can never share what he calls a “contentful” moral life. In fact, his vision of a bioethics for the postmodern world presupposes these radical differences between belief systems—whether religious or secular—and cultures.

However, despite the apparent fact that modernist and postmodernist attitudes toward China and Chinese medical ethics take up opposing evaluative positions, they share a common outlook—what British China scholar Raymond Dawson long ago called the “East is East and West is West” mentality (Dawson 1967). Although the rise of the postmodern discourse has challenged modernist or ethnocentric evaluations of the Eastern “principle,” it still views East and the West as two different worlds which are mutually inscrutable. In other words, although postmodernist discourse has totally reversed the negative stance of modern Orientalists towards the East, belief in the essential, dualistic and radical differences between East and West remains. The most widely circulated generalization is that Chinese and Western cultures are dominated by collectivism (or authoritarianism) and individualism respectively—the former thought of as totalitarianism by its detractors and collectivism or communitarianism by its adherents.

Dichotomizing East and West

The oppositional way of thinking about East and West has a deep intellectual and historical root. Dichotomizing East and West has been a cornerstone of modern Occidental approaches to the Orient. As Edward Said has pointed out in his influential study of Orientalism:

Orientalism is a style of thought based on an ontological and epistemological distinction between ‘the Orient’ and (most of the time) ‘the Occident.’ Thus a very large mass of writers, among whom are poets, novelists, philosophers, political theorists, economists, and imperial administrators, have accepted the basic distinction between East and West as the starting point for elaborating theories, epics, novels, social descriptions, and political accounts concerning the Orient, its people, customs, ‘mind,’ destiny, and so on.

(Said 1994 [1979]: 2–3)

In 1958, the distinguished author of The Logic of Scientific Discovery and The Open Society and its Enemies delivered a public address in Zürich entitled “What does the West believe in?” For Karl Popper, as for Mill and Settembrini, the West properly believes in its own values: rationalism, progress, democracy as the least flawed and thus the best form of government and, most importantly, pluralism of ideas. In his words, “we can say proudly that we in the West believe in many and different things, in much that is true and in much that is false; in good things and in bad things” (Popper 1994: 212). Popper hints that, contrary to the West, where this diversity of thought is not only a prominent feature but also an ideal to be pursued, the East (as represented by Communism) is characterized by a monolithic unity of ideas and thus lacks diversity.

Although the “Cold War” political context of Popper's speech was historically unique and his hostile attitude to the “East” is no longer widely shared, this way of dichotomizing East and West is still commonplace. Ironically, many of the efforts aimed at overcoming the deficiencies of Orientalism—such as a Western postmodernist and a conservative Chinese (to be discussed in the next section) approach to medical ethics—still subscribe to the Orientalist epistemological distinction between East and West.

Historically, this cultural opposition goes far beyond modern times and dates back to the beginnings of Western civilization and literature. The demarcation between the Orient and the Occident was manifested in the Iliad of Homer, The Persians of Aeschylus, and The Bacchae of Euripides. In The Politics, Aristotle compared the people of the colder regions of Europe, the people of Asia, and the people of Greece. The peoples of northern Europe, he said, “are full of spirit, but deficient in skill and intelligence.” The peoples of As...

Table of contents

• Front Cover
• Medical Ethics in China
• Biomedical Law and Ethics Library
• Title Page
• Copyright
• Dedication
• Contents
• Foreword by Robert M. Veatch
• Prologue: “Supping with foreign devils”
• Introduction: the search for a transcultural bioethics
• PART I Beyond stereotypes and stereotyping
• PART II Truths of cultures
• PART III Cultural norms embodying universal values
• PART IV Chinese wisdom for today
• Conclusions: Toward the uncertain future
• Epilogue: Thus spoke Hai Ruo (The God of the North Sea)
• Bibliography
• Acknowledgements
• About the author
• Index