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Toward a Directed Benevolent Market Polity: Rethinking Medical Morality in Transitional China

Published online by Cambridge University Press:  21 May 2008

RUIPING FAN
RUIPING FAN
Affiliation:
Department of Public and Social Administration at City University of Hong Kong
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Extract

Healthcare systems in Singapore, Hong Kong, and mainland China are strikingly distinct from those in the West. Economically speaking, each of the aforementioned Eastern systems relies in great measure on private expenditures supplemented by savings accounts. Western nations, on the other hand, typically exhibit government funding and wariness about healthcare savings accounts. This essay argues that these and other differences between Pacific Rim healthcare systems and Western systems should be assessed in light of background Confucian commitments operating in the former. In the Confucian context, bioethics and healthcare policy have a unique content, texture, and set of implications that often affront Western assumptions about the appropriate individual autonomy of patients and the appropriate character of social safety nets for healthcare.

Type
Special Section: International Voices 2008
Information
Cambridge Quarterly of Healthcare Ethics , Volume 17 , Issue 3 , July 2008 , pp. 280 - 292
Copyright
Copyright © Cambridge University Press 2008

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References

Notes

1 “The way an East Asian interprets another person's actions and makes normative judgments is still powerfully informed by Confucian teachings. This is true even in the political sphere.” Chaihark, H. Constitutionalism, Confucian civic virtue, and ritual propriety. In Bell, DA, Chaibong, H, eds. Confucianism for the Modern World. Cambridge: Cambridge University Press; 2003:31–53at p. 42CrossRefGoogle Scholar.

2 A dominant contemporary neo-Confucian view is that Confucianism must integrate itself with liberal democratic ideals so that Confucian societies can be democratized in these terms. See, for example, Liu, S. Confucian ideals and the real world. In: Tu, W, ed. Confucian Traditions in East Asian Modernity. Cambridge, MA: Harvard University Press; 1996:92–111Google Scholar.

3 An illustrative example in bioethics is the four bioethical principles proposed by Beauchamp, Tom and Children, Jamesin light of modern Western moral thought and experience. They claim that these principles constitute a basic minimum of the common morality that should be applicable normatively to every region of the world. See theirPrinciples of Biomedical Ethics, 5th ed.New York: Oxford University Press; 2001Google Scholar.

4 A good example is afforded by Hong Kong medical ethics, which has come recently to resituate the legal commitments it inherited from its British colonial past within Confucian guidelines for actual clinical practice. The result is that, if one looks to the general governing medical law regarding individually oriented informed consent, one should assume that it was being applied in the same patient-oriented fashion as law in Britain. However, the actual, legally recognized medical ethics norms for clinical practice orient the physician–patient relationship in more family-oriented terms. See Tse, C-Y, Tao, J. Strategic ambiguities in the process of consent: Role of the family in decisions to forgo life-sustaining treatment for incompetent elderly patients. Journal of Medicine and Philosophy 2004;29:207–23Google ScholarPubMed.

5 See, for example, Jian, Q. Political Confucianism. Beijing: Sanlian Book House; 2003Google Scholar; Kang, X. Benevolent Government. Singapore: Global Publishing Company; 2005Google Scholar.

6 “The first among the East Asians to openly and enthusiastically espouse the idea that Confucianism had much to do with the rapid industrialization of the region were politicians. Most notoriously, Singapore's senior statesman Lee Kuan Yew has invoked Confucian values—under the guise of ‘Asian values’—with the apparent aim of justifying constraints on the democratic process. Authoritarian governments in the region have similarly appealed to Confucian values meant to contrast with Western-style democracy…. Confucian principles may also help to explain the fact that contemporary East Asian states rely mainly on nonstate agencies—community, firm, and family—to finance and provide welfare services, with significantly less direct state financing of services than other developed states.” Bell, DA, Chaibong, H. The contemporary relevance of Confucianism. In: Bell, DA, Chaibong, H, eds. Confucianism for the Modern World. Cambridge: Cambridge University Press; 2003:1–28at pp. 3, 17CrossRefGoogle Scholar. See, also, Goodman, R, White, G, Kwon, H, eds. The East Asian Welfare Model: Welfare Orientalism and the State. London: Routledge; 1998Google Scholar.

7 There are numerous legitimate concerns about how to check power and to avoid abuse in such East Asian polities as have just been described. Any reflection upon these concerns would require addressing a considerable literature and exploring a long list of issues. Such falls beyond the compass of this article. Here the attempt has been much more modest: to offer a Confucian reconstruction of social and political reality one encounters. Also the Confucian tradition literature itself addresses issues of checking the abuse of power and establishing appropriate balancing institutions; this too falls beyond the endeavors of this essay.

8 Chan, H. Informed consent Hong Kong style: An instance of moderate familism. Journal of Medicine & Philosophy 2004;29:195–206CrossRefGoogle ScholarPubMed; Fan, R, Tao, J. Consent to medical treatment: The complex interplay of patients, families, and physicians. Journal of Medicine & Philosophy 2004;29:139–48CrossRefGoogle ScholarPubMed.

9 Cherry, MJ, Engelhardt, HT Jr. Informed consent in Texas: Theory and practice. Journal of Medicine & Philosophy 2004;29:237–52CrossRefGoogle ScholarPubMed.

10 Fan, R, Li, BF. Truth telling in medicine: The Confucian view. Journal of Medicine & Philosophy 2004;29:179–93CrossRefGoogle ScholarPubMed.

11 Cong, Y. Doctor-family-patient relationships: The Chinese paradigm of informed consent. Journal of Medicine & Philosophy 2004;29:149–78CrossRefGoogle Scholar.

12 Duff, J. Financing to foster community health care: A comparative analysis of Singapore, Europe, North America and Australia. Current Sociology 2001;49(3):135–54CrossRefGoogle Scholar; Healthcare Research Group. Health Services in Singapore: A Strategic Entry Report, 1999. San Diego, CA: Icon Group International; 1999Google Scholar.

13 The Confucian account offered in this section is based on the views of classical Confucian figures, Confucius, Mencius, and Xunzi, without addressing any disagreement among them. Their disagreements, if any, are not relevant to the argument of this essay. See Confucian Analects, the Great Learning & the Doctrine of te Mean, Legge, J, trans.; New York: Dover Publications; 1971Google Scholar; The Works of Mencius, Legge, J, trans.; New York: Dover Publications; 1970Google Scholar; Xunzi, Knoblock, J, trans.; Stanford, CA: Stanford University Press; 1988Google Scholar.

14 To read such social democratic concepts into Confucianism involves, at best, a form of naïve presentism and, at worst, a reconstruction of the past to meet the conceits of the contemporary age. It would produce a new account (i.e., a reform Confucianism, if you will) but would not constitute a presentation of the background cultural understandings currently influencing the moral and political thought of many people in the Pacific Rim. Unfortunately, some most influential contemporary neo-Confucians took pains to develop democracy from Confucian thought. For instance, see Mou, T. Moral Idealism (Dao De Li Xiang Zhu Yi). Taibei: Xue Sheng Shu Ju; 1985Google Scholar; Politics and Governance (Zheng Dao yu Zhi Dao). Taibei: Xue Sheng Shu Ju; 1987Google Scholar; Philosophy of History (Li Shi Zhe Xue). Taibei: Xue Sheng Shu Ju; 1988Google Scholar. For an excellent analysis of the failure of his endeavors, see Jiang, Q. Political Confucianism (Zheng Zhi Ru Xue). Beijing: San Lian Shu Dian; 2003Google Scholar.

15 For a brilliant exposition of the Confucian view of li, see Fingarette, H. Confucius—The Secular as Sacred. New York: Harper & Row; 1972Google Scholar. For a systematic exploration of the appropriate relation between ren and li for Confucius, see Shun, K. Ren and Li in the Analects. In: van Norden, BW, ed. Confucius and the Analects: New Essays. New York: Oxford University Press; 2002:53–72Google Scholar. For a collection of the 20th century Chinese research on li, see Chen, Q, Guo, W, Zhou, X, eds. Treatises on Chinese Rites Research in the 20th Century (Er Shi Shi Ji Zhong Guo Li Xue Yan Jiu Lun Ji). Beijing: Xue Yuan Press; 1998Google Scholar.

16 For a very helpful exploration of Confucian elitism as well as its favored way of selecting officials through examination rather than democratic election, see Bell, DA. East Meets West. Princeton, NJ: Princeton University Press; 2000CrossRefGoogle Scholar.

17 The Chinese system of private ownership already formed in the Warring-Sate Period of China more than 2000 years ago. Confucians before Mencius may have supported a special public-ownership system, the so-called Well-field System of Land. However, as Zhao and Chen indicate in Zhao, G, Chen, Z. A History of Chinese Economic Systems (Zhongguo Jinji Zhidushi). Beijing: Chinese Economic Press; 1991Google Scholar, Mencius' call for “forming property for the people” (wei min zhi chan) helped to bring about the privatization of land. Since Mencius, Confucians have always supported a market system based on private ownership (p. 5).

18 For a vivid exposition of Confucian family values, see Liang, S. The Essential Meaning of Chinese Culture (Zhong Guo Wen Hua Yao Yi). Shanghai: Shanghai People's Press; 2003Google Scholar.

19 See, for example, Redding, SG. Societal transformation and the contribution of authority relations and cooperation norms in overseas Chinese business. In: Tu, W, ed. Confucian Traditions in East Asian Modernity. Cambridge, MA: Harvard University Press; 1996:310–28Google Scholar.

20 “Barefoot doctors” refer to a group of young peasants who were selected to accept a short-time medical training and to offer medical care for the peasants while at the same time participating in manual agricultural labor by themselves. See Kunming Medical School Institute of Health, ed. From Barefoot Doctors to Village Doctors. Kunming: Yunnan People's Press; 2002Google Scholar.

21 See, for example, Zhou, S et al. The development of medical care in the Chinese countryside (Nongcun Hezhou Yiliao de Fazhan). In: Research on the Chinese Medical Care Systems in Chinese Rural Areas (Zhongguo Nongcun Yiliao Tizhi Yanjiu). Shanghai: Shanghai Science and Technology Press; 1991:15–20Google Scholar.

22 See Alitto, GS. The Last Confucian: Liang Shu-ming and the Chinese Dilemma of Modernity, 2nd ed.Berkeley: University of California Press; 1986:324–30Google Scholar.

23 The People's Republic of China State Council Decree 44/1998.

24 Table 1 was created with adapted English translations of the information offered by the National Survey on Health Care Service in 2003; available at http://www.moh.gov.cn/open/statistics/digest06/y25.htm (accessed on 24 Aug 2007).

25 State Council Development Research Center on the Health Care Reforms; see China News Network; available at http://news.sina.com.cn/c/2005-07-29/12246561593s.shtml (accessed on 24 Aug 2007)Google Scholar.

26 Such judgments have been echoed by some Western scholars from views grounded in liberal social-democratic ideology. See, for example, Blumenthal, D, Hsiao, W. Privatization and its discontents—The evolving Chinese health care system. The New England Journal of Medicine 2005;353:1165–70CrossRefGoogle ScholarPubMed.

27 Goodman, R, White, G, Kwon, H, eds. The East Asian Welfare Model: Welfare Orientalism and the State. London: Routledge; 1998Google Scholar.

28 Smith, C, Cowan, C, Sensenig, A, Catlin, A, Health Accounts Team. Health spending growth slows in 2003. Health Affairs 2005;24:185–94 at p. 189CrossRefGoogle ScholarPubMed.

29 Anderson, GR, Poullier, JP. Health spending, access, and outcomes: Trends in industrialized countries. Health Affairs 1999;18:178–92 at p. 181CrossRefGoogle ScholarPubMed.

30 The sources of the information for Table 2 are the following websites (accessed on 24 Aug 2007):

  1. 1)

    1) WHO: http://www.who.int/whr/2004/annex/country/sgp/en/index.html, http://www.who.int/whr/2004/annex/country/chn/en/index.html, http://www.who.int/whr/2004/annex/country/usa/en/index.html, http://www.who.int/whr/2004/annex/country/gbr/en/index.html.

  2. 2)

    2) Hong Kong government: http://www.hwfb.gov.hk/hmdac/english/dis_papers/dis_papers_lhcshk.html.

  3. 3)

    3) Winterthur Insurance (Far East) Pte Ltd: http://www.irmi.com/Expert/Articles/2002/Kristensen09.aspx.

  4. 4)

    4) XL Winterthur International Co. Ltd.: http://www.irmi.com/Expert/Articles/2002/Kristensen03.aspx.

  5. 5)

    5) Chinese National Survey on Health Service: http://www.moh.gov.cn.

  6. 6)

    6) U.S. Census: http://www.census.gov/prod/2004pubs/p60-226.pdf.

  7. 7)

    7) National Statistics (UK): http://www.statistics.gov.uk/StatBase/ssdataset.asp?vlnk=5053&Pos=&ColRank=2&Rank=272.

31 See Chinese Bureau of Statistics. China's Statistics on Economic and Social Development in 2005; available at http://www.stats.gov.cn/tjgb/ndtjgb/qgndtjgb/t20060227_402307796.htm (accessed on 24 Aug 2007)Google Scholar.

32 For instance, economic reform so far has given the peasants' families a right to manage their production on land, but not a right to own land. Rural land is often sold to land developers by local governments and village chiefs without benefiting the peasants. That is, the Chinese peasants still have not obtained reliable private property in Mencius's sense, so that they cannot control their land as they wish and consequently raise their standard of living, healthcare included. Accordingly, quality basic healthcare for the Chinese peasants, like other items such as education and housing, have to be achieved by their first securing a right to own their land.

33 For detailed analyses and explorations of the corruptions in the current Chinese healthcare reality, see my Corrupt practices in Chinese medical care: The root in public policies and a call for Confucian-market approach. Kennedy Institute of Ethics Journal 2007;17(2):111–31CrossRefGoogle Scholar.