Developing a culturally relevant bioethics for Asian people

Because of cultural differences between East and West, any attempt at outright adaptation of Western ideas in Asia will undoubtedly encounter problems, if not rejection. Transferring an idea from one place to another is just like transplanting an organ from a donor to a recipient--rejection is to be expected. Human cultures respond to new ideas from different value systems in very much the same way. Recently, biomedical ethics has received much attention in Asia. Fundamental advances in medicine have motivated medical scientists to look at the ethical issues arising from this progress. Will the principles upheld by the bioethicists in the West meet the challenge in Asia? This article argues that Asian bioethicists must develop a bioethics responding to their own cultural contexts. If Western principles are adopted, then they must be re-interpreted and even modified, if necessary, in light of Asian beliefs.

How should doctors approach patients? A Confucian reflection on personhood

The modern doctor-patient relationship displays a patient-centred, mutual-participation characteristic rather than the former active-passive or guidance-cooperation models in terms of medical decision making. Respecting the wishes of patients, amounting to more than mere concern for their welfare, has become the feature central to certain modern bioethics theories. A group of ethical principles such as respect for autonomy, beneficence, non-maleficence, and justice has been proposed by bioethicists and widely adopted by many medical societies as an ethical guide to how doctors, in their daily practice, should treat their patients. However, seeing patients as persons who are rational, self-conscious beings capable of valuing their own lives, and who are consequently entitled to the liberty and rights to choose for themselves, is in general the backbone of Western bioethical principles. Since Confucian philosophy has long been a representative of the East-Asia cultural tradition and Confucian bioethics has recently been developed as a theory of applied ethics, examining Confucius's idea of "persons" may shed some light on the current bioethical debates. Confucius's concept of persons, which is best interpreted via his theories of "chun-tze", (the morally ideal person) encapsulating a two-dimensional approach, (the "autonomous person" and the "relational person"), provides a more comprehensive model regarding what a person is and how he/she should be treated. This two-dimensional approach sees a person not only as a rational, autonomous agent but also as a relational, altruistic identity whose self actualisation involves incessant participating in and promoting of the welfare of his fellow persons. Hence this may balance the current bioethical trend whereby "respect for autonomy" often triumphs.

Bioethics for clinicians: 20. Chinese bioethics

Chinese Canadians form one of the largest groups in the Canadian cultural mosaic. Many of the assumptions implicit in a Western autonomy-based approach to bioethical deliberation may not be shared by Chinese Canadians. In traditional Chinese culture, greater social and moral meaning rests in the interdependence of family and community, which overrides self-determination. Consequently, many Chinese may vest in family members the right to receive and disclose information, to make decisions and to organize patient care. Furthermore, interactions between Chinese patients and health care workers may be affected by important differences in values and goals and in the perception of the nature and meaning of illness. Acknowledging and negotiating these differences can lead to considerable improvement in communication and in the quality of care.

The Confucian relational concept of the person and its modern predicament

The Confucian relational concept of the person has been proposed as an epistemically more cogent and ethically more attractive alternative to that of liberal individualism. Two arguments are raised against this proposal without defending liberal individualism. Ethically, Confucianism is vitiated by certain unattractive features that cannot be removed without reducing the Confucian relational concept of the person to an abstract and not very helpful notion of human relatedness. Epistemically, Confucianism commits the essentialist fallacy of treating its own concept of human relations as reflecting the nature of things. In view of these limitations, the Confucian relational concept of the person does not provide a viable framework for dealing with social issues including bioethics.

Does it really care? The Harvard report on health care reform for Hong Kong

This paper aims to provide a rendition of the care ethic in Confucian philosophy and to argue that social policy developments in Hong Kong society, including health care policy, have been significantly shaped and justified in terms of the ideal of care in the Confucian moral tradition. On the basis of this analysis, the paper raises a number of questions about a recent proposal for health care reform for Hong Kong put forth by the Harvard School of Public Health which argues for adopting the principle of equity as the overriding value for the moral foundation of Hong Kong's health care system. The paper examines how the over-emphasis on equity in the Harvard Report proposals can lead to the erosion of care and ultimately the eclipse of the vision of care in Hong Kong's health care system. It argues that the pursuit of equity, which is itself a valuable principle, should not displace the importance of the value of care or undermine the ideal of care and that health care decisions must be firmly embedded in local cultures and moral traditions.

Free choice, equity, and care: the moral foundations of health care

The aims of this paper are threefold. The first aim is to provide a critique of the reform proposal of the Harvard School of Public Health for Hong Kong's health care system through privatization of the public sector services. The second aim is to argue for the duty of society to guarantee every member equal access to a basic level of health care based on the values of equity, care and free choice. The third aim is to explore some suggestions about delivery structures and financial arrangements of a dual sector health care system which will better enable society to provide a basic level of health care that is sustainable and affordable, while being at the same time consistent with the values of care, equity and free choice.

The problem of coerced abortion in China and related ethical issues

Since the early 1970s, despite popular opposition, to control the rapid growth of population the Chinese government has been carrying out the strictest and most comprehensive family planning policy in the world. In addition to contraceptive methods and sterilization, artificial abortion—both surgical and nonsurgical—has been used as an important measure of birth control under the policy. Many women have been required, persuaded, and even forced by the authorities to abort fetuses no matter how much they want to give birth.

Ancient Chinese medical ethics and the four principles of biomedical ethics

The four principles approach to biomedical ethics (4PBE) has, since the 1970s, been increasingly developed as a universal bioethics method. Despite its wide acceptance and popularity, the 4PBE has received many challenges to its cross-cultural plausibility. This paper first specifies the principles and characteristics of ancient Chinese medical ethics (ACME), then makes a comparison between ACME and the 4PBE with a view to testing out the 4PBE's cross-cultural plausibility when applied to one particular but very extensive and prominent cultural context. The result shows that the concepts of respect for autonomy, non-maleficence, beneficence and justice are clearly identifiable in ACME. Yet, being influenced by certain socio-cultural factors, those applying the 4PBE in Chinese society may tend to adopt a "beneficence-oriented", rather than an "autonomy-oriented" approach, which, in general, is dissimilar to the practice of contemporary Western bioethics, where "autonomy often triumphs".

The ambiguity about death in Japan: an ethical implication for organ procurement

In the latter half of the twentieth century, developed countries of the world have made tremendous strides in organ donation and transplantation. However, in this area of medicine, Japan has been slow to follow. Japanese ethics, deeply rooted in religion and tradition, have affected their outlook on life and death. Because the Japanese have only recently started to acknowledge the concept of brain death, transplantation of major organs has been hindered in that country. Currently, there is a dual definition of death in Japan, intended to satisfy both sides of the issue. This interesting paradox, which still stands to be fully resolved, illustrates the contentious conflict between medical ethics and medical progress in Japan.

A transcultural, preventive ethics approach to critical-care medicine: restoring the critical care physician's power and authority

This article comments on the treatment of critical-care ethics in four preceding articles about critical-care medicine and its ethical challenges in mainland China, Hong Kong, Japan, and the Philippines. These articles show how cultural values can be in both synchrony and conflict in generating these ethical challenges and in the constraints that they place on the response of critical-care ethics to them. To prevent ethical conflict in critical care the author proposes a two-step approach to the ethical justification of critical-care management: (1) the decision to resuscitate and initiate critical-care management, which is based on the obligation to prevent imminent mortality without permanent loss of consciousness; and (2) the decision to continue critical-care management, which is based on the obligation both to prevent imminent death without permanent loss of consciousness and to avoid unnecessary, significant iatrogenic costs to the patient and psychosocial costs to the family when the reduction of mortality risk is marginal. Physicians and hospitals should restore the critical-care physician's authority and power -- against prevailing cultural values, if necessary -- to control when critical-care intervention is offered, when it is recommended to continue, and when it is recommended to be discontinued and the patient allowed to die.

Cultivating a moral sense of nursing through model emulation

This paper reports part of a longitudinal research project, which sought to capture students' conceptualization of caring practice as they progressed to different levels of study in a nursing diploma programme in Hong Kong. Model emulation was found to be an effective means of focusing students' learning processes on the moral aspects of nursing practice. The theory of model emulation from a Chinese perspective and how it is applied to create a learning context to allow students to acquire a moral sense of nursing are discussed. The participating students are invited to be sincere enquirers in the pursuit of the good embedded in practice through introspective self-examination and dialogue. They are asked to describe and share their experience of positive and negative examples of nursing in written accounts. Van Kaam's phenomenological method was adopted to explicate the good and bad constituents of nursing from these examples, with the students assuming an active role in the explication process. The explication reveals that the students were able to articulate the good and bad practices in a variety of patient care situations.

Asian and Pacific Islander cultural values: considerations for health care decision making

As the United States becomes more ethnically diverse, health care practitioners must learn about the perspectives and values of a variety of cultural groups. Of interest is how these cultural values intersect with those of the dominant culture, especially in the health care arena. This article explores the values that influence decision making among Asian and Pacific Islander cultures, with specific illustrations from six of these cultures. The literature, along with our observations as health professionals and researchers working in Hawaii, suggest potential areas of conflict between the more collectivist values of Asian and Pacific Islander cultures and the more individualist orientation of the U.S. health care system. Implications for practice and research are presented.

Self-determination vs. family-determination: two incommensurable principles of autonomy: a report from East Asia

Most contemporary bioethicists believe that Western bioethical principles, such as the principle of autonomy, are universally binding wherever bioethics is found. According to these bioethicists, these principles may be subject to culturally-conditioned further interpretations for their application in different nations or regions, but an 'abstract content' of each principle remains unchanged, which provides 'an objective basis for moral judgment and international law'. This essay intends to demonstrate that this is not the case. Taking the principle of autonomy as an example, this essay argues that there is no such shared 'abstract content' between the Western bioethical principle of autonomy and the East Asian bioethical principle of autonomy. Other things being equal, the Western principle of autonomy demands self-determination, assumes a subjective conception of the good and promotes the value of individual independence, whilst the East Asian principle of autonomy requires family-determination, presupposes an objective conception of the good and upholds the value of harmonious dependence. They differ from each other in the most general sense and basic moral requirement.

AIDS, policy and bioethics: ethical dilemmas facing China in HIV prevention: a report from China

The present situation of the HIV/AIDS epidemic is very grim in China. The probability of China becoming a country with a high prevalence of HIV/AIDS cannot be excluded because there have been factors which promote the wide spread of HIV if we fail to take timely action to prevent it at the opportune moment. However, China's HIV prevention policy is inadequate. Health professionals and programmers believed that they could take a conventional public health approach to cope with the HIV epidemic. They simply ignored the fact that HIV infection is an epidemic so special that their approach is not effective to deter the epidemic. Many health professionals and programmers bypassed ethical issues that had emerged in the prevention of the HIV epidemic. Even some health educators, sexologists and officials believe that 'AIDS is the punishment for promiscuity', and this belief has led to discrimination and stigmatization of AIDS patients, HIV positive people, their family members and high risk groups. Although homosexuality is not illegal, the police can always find any reason to detain homosexuals. A difficult ethical issue is about the laws prohibiting prostitution and drug use in China which force prostitutes and intravenous drug users underground, giving them no chance to access information, education and the services needed to protect them. The dilemma facing China is whether to stay with a restrictive policy for the reason of ideology cleansing or to turn to a more supportive policy. It is necessary to have some change in the ethical framework to evaluate the action in HIV prevention. Tolerance should be the first ethical principle.

Human rights and Japanese bioethics: a report from Japan

The main contentions of this paper are two fold. First, there is a more than century-old Japanese tradition of human rights based on a fusion of Western concepts of natural rights and a radical reinterpretation of Confucianism, the major proponent of which was the Japanese thinker Nakae Chomin. Secondly, this tradition, although a minority view, is crucial for remedying the serious defects in the present Japanese medical system. In the latter half of the nineteenth century, Nakae Chomin sought to reinterpret Chinese tradition, especially Confucianism, by injecting the concepts of popular sovereignty and democratic equality, drawn from Western sources. The resulting view maintained the Confucian commitment to a moral nexus for society, but replaced hierarchy with egalitarianism. The pressing need for such an approach to patients' rights in present-day Japan is illustrated by two recent cases: the photographing and commercial exploitation of patients' genitals without serious response by authorities, and the attempt by physicians to manipulate the time of death and, possibly, to improperly pressure family members in order to transplant organs from the brain-dead victim of a criminal assault. Such problems stem from hierarchy and paternalism, which seem to be a legacy of the rapid, state-sponsored introduction of Western medicine in the mid-nineteenth century, and in particular from the government's adoption of and support for German military medicine as a model for Japan.

A view of death and dying among the Chinese and Japanese

The practices of medicine around the world have been fused into that of faith and religion. In serving our patients' need to accept death, physicians must also be sensitive to this underlying basic human concern as they prepare for this final journey. The Chinese and Japanese, reflecting their belief in Buddhism, perceive death as a natural part and an extension of life itself.

Cultural issues in death and dying

Although all of us experience death, not all of us think about death or respond to death the same way. This study begins to explore how cultural traditions, education, and tenure in Hawaii impact views of advanced directives, organ donation, suicide, and euthanasia. This information is useful to physicians who need to engage patients and families in discussions about death and end-of-life decision making.

Chinese Confucian culture and the medical ethical tradition

The Confucian culture, rich in its contents and great in its significance, exerted on the thinking, culture and political life of ancient China immense influences, unparalleled by any other school of thought or culture. Confucian theories on morality and ethics, with 'goodness' as the core and 'rites' as the norm, served as the 'key notes' of the traditional medical ethics of China. The viewpoints of Confucianism on benevolence and material interests, on good and evil, on kindheartedness, and on character cultivation were all inherited by the medical workers and thus became prominent in Chinese traditional medical ethics. Hence, it is clear that the medical profession and Confucianism have long shared common goals in terms of ethics. Influenced by the excellent Confucian thinking and culture, a rather highly-developed system of Chinese traditional medical ethics emerged with a well-defined basic content, and the system has been followed and amended by medical professionals of all generations throughout Chinese history. This system, just to mention briefly, contains concepts such as the need: to attach great importance to the value of life; to do one's best to rescue the dying and to heal the wounded; to show concern to those who suffer from diseases; to practise medicine with honesty; to study medical skills painstakingly; to oppose a careless style of work; to comfort oneself in a dignified manner; to respect local customs and to be polite; to treat patients, noble or humble, equally, and to respect the academic achievements of others, etc. Of course, at the same time, Confucian culture has its own historical and class limitations, which exerted negative influences on traditional medical ethics. Now, if we are to keep up with the development of modern medicine, a serious topic must be addressed. That is how to retain the essence of our traditional medical ethics so as to maintain historic continuity and yet, at the same time, add on the new contents of medical ethics so as to incorporate modern features into our system. Therefore, when trying to reform medical practice in China, we are faced with the urgent need to inherit and promulgate the essence of Confucian ethics--discarding its obsolete concepts--while at the same time building up the new medical ethics that can meet the requirements of the outside world and the future.