Bioethics began in the 1980s in China, being borrowed and introduced from western countries. But the Chinese bioethics has been seeking a different model from western bioethics, grounded on its philosophical basis and cultural environment. Some significant progress has been achieved in the academic field of bioethics, the policy makers and government regulation. Though China shares some common bioethical issues and discussion with other countries, China is facing some special challenges, including Doctor-Patient-Relationship, and health inequality in health care reform.
En China, la bioética comenzó en la década de 1980, traída y adoptada desde países occidentales. Pero la bioética china ha buscado un modelo diferente a la occidental, fundamentado en las bases filosóficas y culturales propias de esta región. Se han logrado avances significativos en el campo académico de la bioética, así como entre los creadores de políticas y regulaciones gubernamentales. Si bien China comparte cuestiones y debates bioéticos comunes con otros países, esta nación se enfrenta a desafíos especiales, tales como la relación médico-paciente y la inequidad en la atención médica en la reforma sanitaria.
As a matter of fact, the term “bioethics” was borrowed from the West by Chinese scholars in the 1980s. Before that time, there is no “bioethics” in the academic field in the strict sense. While some western scholars deem “bioethics” as a new field devoted to human survival and an improved quality of life (Callahan, 1995, p. 250), the Chinese bioethicists regard medical ethics as a much broader category, where bioethics is an extension and a branch of medical ethics (Qiu, 1987, p. 6). In the beginning, bioethics was mainly taught by people working on medical ethics in medical schools. In the late 1990s, bioethics grows much broader, and now it is a discipline broader than medical ethics.
The development of Bioethics in ChinaFirst two cases related to the beginning and end of lifeThe first legal case of Artificial Insemination by Donor
The first legal case of Artificial Insemination by Donor (AID) – happened in Shanghai in 1987 – initiated the public ethical discussion on Assisted Reproduction Technology (ART) in China. It was about a couple that got one son by AID, but the husband could not accept the son under the pressure of his family. Finally the couple divorced, and kicked the mother and son out of the door. One year later, the first Chinese test-tube baby in mainland was born in Beijing. Since then, the assisted reproductive technology has developed constantly. At the very beginning, some opponents argued that AI violated the nature of human reproduction; destroyed marriage which they considered as one of the most significant relationships among people. While others suggested that such skill could enhance the family happiness for some infertile couples without doing any harm to others. As for the In Vitro Fertilization and Embryo Transfer (IVF-ET), the first issue was the difficulty to identify the “parents” of the baby, within a culture deeply linked with the pattern of blood relationship. China shares much similarities with other countries on the subject of technology related to reproduction, precisely because China holds a strong traditional character which includes the blood line and genetic line among the roots of many ethical issues.
Euthanasia caseThe first euthanasia case occurred in Hanzhong City, Shaanxi Province in 1986. Xia Suwen was hospitalized for a liver disease on June 23, 1986, diagnosed as liver cirrhotic ascites, hepatic encephalopathy and exudative ulcer and bedsore. She felt better after some treatment; however, her condition turned worse on June 27 and suffered pain and anxiety, once expressed that she didn’t want to live. In the morning of June 28, she fell into a coma. Her youngest son Wang Mingcheng knew that it was impossible to cure her and asked for help from the physician Pu. Finally, Pu prescribed 100ml chlorphomazine after that Wang had signed on the prescription that he accepted all the responsibilities. Xia died in the early morning of June 29. Xia's death raised fierce reactions from the public and in September Wang and Pu were arrested. Since there was no such case or legislation before, and considering the impact of such an issue, the court finally pronounced tin 1992 that hey were not guilty, and regarded as the direct cause of Xia's death her liver disease rather than the chlorphomazine. The trial had lasted for five years.
The discussion went on though this case finished after the final verdict. Nowadays there is still no consensus on euthanasia in China. However, since the last decade, almost every year during the sessions of the National People's Congress proposals for euthanasia legalization are presented, but are always rejected. Actually, the legislation of euthanasia still has a long way to go in the context of China. Owing to imperfections in our Health System and Social Security System, it is hard to identify and guarantee the voluntariness of informed consent. Financial factors, regarding the unaffordability of healthcare and nursing, as well as family decision-making pattern make such issue more complex.
Other major topics of Bioethics in ChinaBesides the issues related to beginning and end of life, Chinese bioethics shares common areas and problems with western countries, including radical and controversial ethical problems: for example, the problems evoked by the practice of surrogate mother which closely combine with women's rights and social justice. Or the issue of the moral status of the IVF embryos: do they have, before transfer, the same status as the normal embryos? However, Chinese bioethics faces some issues with its own reasons, e.g. the Doctor-patient relationship (DPR), organ transplantation, health policy and health resources distribution, human subject protection, etc.
Doctor-Patient Relationship (DPR) in ChinaThe growing deterioration of DPR is now one of the most serious problems in Chinese society. The decrease of trust between health professionals and patient/patient family makes DPR not only an issue in medical ethics and bioethics, but also a social problem: several doctors were killed, more sue cases come to court. Reasons for such a fragile DPR in China are multidimensional. From the perspective of doctors, the imbalanced patient/physician ratio prevents physicians from guaranteeing enough time and devotion to treat their patients carefully enough. This happens in big hospitals in big cities, because few patients go to small hospitals or clinics in small communities. The “defensive” medicine is in China another important factor. Afraid of being sued or bearing some other responsibilities, many physicians become more conservative when treating patients and this seriously affects the quality of health services. From the patient point of view, the awareness of personal rights - increased rapidly in recent years – goes along with the collapse of the traditional authority of physicians that formed the basic image for patients. The blunt improvements of the health service or related health infrastructures buildings (that are far from satisfying the medical and non-medical needs of people) resulted in difficulties of accessing health services and in high cost. According to a national survey carried in 2010, about 50% of patients would give a “red envelope” (filled with money or other kinds of gift) to their physician in order to purchase their “special care” and “higher quality treatments” prescription (Kong, X., & Du, Z. 2011). In the 12th-five-year-plan (covering the last five years) the Chinese government has reformed the healthcare system, and one big achievement was that 95% of the population can enjoy basic healthcare insurance. This should significantly improve the satisfaction of access to healthcare, and DPR will be improved as well.
Organ TransplantationAs in all countries over the world, China is facing common problems such as the scarcity of organs, the disparity in distribution of organ resources, the possible complications in the long run resulting from the imperfection of transplant techniques etc. In 1999, a doctor in Beijing took off without informed consent or authorization the eyeballs of a dead body to treat another patient, and this caused strong debate and reflection in both the medical and the legal profession. That behavior was considered unethical but no proper regulations existed to cope with it. To regulate the human organ transplantation, and protect the rights of citizens, the Chinese Central Government promulgated a Regulations of Human Organ Transplantation in 2007 according to which the basic principle is that organ donation must be voluntary and free. Nowadays, more and more organ transplantations by living donor (e.g kidney) are delivered. According to our regulation, the living donor must be at least 18 years old and all requests of living donation must apply for the review of ethical committees and get their approval. Actually, there were some cases of “fake donor”, due to the use of fake personal identity document.
One point is worth mentioning. The debate on using organs taken from persons sentenced to death penalty is gradually decreasing because Chinese government officer (former vice Minister of Health) Huang Jiefu has announced formally to stop such organ resources after 2015.
Human Genome Research and stem cellsFormer MOH (Ministry of Health) and MOST (Ministry of Science and Technology)issued in 2003 the Ethical Guidelines for Human Embryonic Stem Cell Research. These guidelines stipulate that human embryonic stem cell research must follow three basic norms: 1) the in vitro culture period of blastomeres cannot be more than 14 days since fertilization or transfers; 2) such human blastula cannot be implanted into any human or animal reproductive system; 3) hybridization between human germ cells and other species’ is prohibited. The guidelines also require that all such researches should be reviewed by an independent ethical committee. When involved in the international genetic researches, the collection and transfer of genetic resources and samples must comply with the requirements of the Interim Measures for the Administration of Human Genetic Resources issued by MOST in 1998. This regulation was revised and approved in 2015, it emphasized strict regulation regarding the collection, selling and buying, export, etc.
Human Subject ProtectionMany big hospitals and medical universities in China have set up their own IRBs (Institutional Review Boards)to review biomedical research protocols involving human subjects, in order to protect the rights and welfare of subjects as well as to guarantee the quality of investigation, according to the regulation issued by the State Food and Drug Administration (SFDA) in 2003 and the formal MOH document in 2007. They are more focused on the areas of clinical drug/medical device trails, and clinical research. At the provincial level, Shanghai Health Bureau is one of the pioneers that set up ethical review committees (ERC), and also leads the discussion on regional level criteria. The case of golden rice raised a lot of concern on informed consent, research integrity, and the quality of IRB. This case occurred in 2012 in Hunan province, and regarded the question whether the gene transferred rice was an equivalent of plant carotenoids in the treatment of children for Vitamin A deficiency. (http://www.chinacdc.cn/zxdt/201209/t20120905_68591.htm) Chinese culture advocates natural food, and the public is sensitive to gene modified food. That is the big background for this China-US collaborative study.
Conflict of InterestIn 2001, professor Jeffrey Kahn from the University of Minnesota and Professor Renzong Qiu gave their presentation and published their articles on Conflict of Interest (COI) in the Journal of Medicine and Philosophy, which might be the earliest literature in China discussing and introducing COI in medical research. Till now there are more and more papers on COI in domestic medical research, and COI is being paid more attention due to its nature related to hospital management mechanism and trust within society towards medical profession. As for the academic discussion, COI is one of the themes in the Annual China-US Conference on Medical Professionalism organized by the Center for China-US Medical Professionalism, PUHSC since 2010.
In fact, some other topics are also hot discussed, including environmental ethical issues, food safety, neuroethics, biobank, and healthcare reform.
Scholars and their woksIn the early 1980s, the first generation scholars, such as, Prof. Renzong Qiu, Zhizheng Du, Ruicong, Peng, Zhaoxiong He, Hongzhu Zhang, Benfu Li and Dapu Shi, etc. brought in bioethics in China. They have published a series of textbooks and monographs. The first textbook of medical ethics after the Cultural Revolution was Outlines of Medical Ethics published by Zhizheng Du in 1985. Renzong Qiu published a textbook Bioethics in 1987 which was the first book that made systematically introduction of western bioethics in China. Zhaoxiong He's History of Chinese Medical Morality published in 1988 introduced systematic development of medical ethics in China. Benfu Li published the Textbook of Medical Ethics which is still widely used by medical universities in 1996. Another influential book Survey of Chinese and Foreign Medical Moral Standards, published by Hongzhu Zhang in 2000, contains a full and accurate understanding of moral codes. Now the Encyclopedia of China Medicine (Medical Ethics volume) edited by Zhizheng Du will come out in near future. On the other hand, there are some significant translation works in bioethics as well. Shen Liu translated Singer's Practical Ethics in 2005; Ruiping Fan translated the Foundation of Bioethics (H. Tristram Engelhardt, Jr., second edition) in 2006. The translation of the Classic Cases in Medical Ethics (fourth edition) published by Jingbao Nie and Linying Hu in 2010 and the Intervention and Reflection: Basic Issues in Medical Ethics also translated by Xia Lin in the same year. A big variety of textbooks of Medical Ethics and Bioethics has been published by second generation bioethics scholars (Zhang, H., & Cong, Y. 2014).
Education in bioethicsFor undergraduate education, Bioethics is a course in some general comprehensive universities, and in medial universities. Also, since the last decade, there are more and more master and PhD programs of bioethics and medical ethics in universities.
Medical ethics course is required by the Ministry of Education in all medical universities, but bioethical courses not yet. The core curriculum of medical ethics and bioethics both need to be discussed and released in order to provide better education for future biomedical researchers and practitioners.
Other infrastructure of BioethicsSome influential journals commenced witnessing and contributing to the fostering of bioethics development in China. Medicine and Philosophy (started in 1980); Chinese Journal of Medical Ethics (started in 1988) play a determinant role in the promotion of various ethical researches and public discussions in China. Other journals, like Medicine and Society, Research on Natural Dialectics, Morality and Civilization, Philosophy Trend, Medical Education are also influential. The Review of Chinese Medical Humanities is also becoming more and more influential.
Several societies and associations related to bioethics were founded at various levels all over China. One of the most prominent is the Medical Ethics Society founded in 1988 as a branch of the Chinese Medical Association (CMA). In August, 2015, the 18th Annual Symposium of Medical Ethics Society, CMA was held in Shanghai. The Chinese Bioethics Society was founded (plan) in 2007 under the Chinese Society for Dialectics of Nature/Philosophy of Nature, Science and Technology, and the annual National Bioethics Conference is organized by this since 2007. A landmark worth particularly mentioning was the eighth World Congress of Bioethics held in Beijing in 2006.
Moreover, a number of bioethics centers have been established in some universities and institutions. For example, the Chinese Academy of Medical Sciences and the Peking Union Medical College in Beijing, Fudan University in Shanghai, Huazhong University of Science and Technology in Wuhan, Shandong University in Ji’nan, Southeast University in Nanjing, Guangzhou Medical College, etc.
Government level regulationsTransferring the consensus into policy is one of the most important tasks of Bioethics. During the last two decades, the Chinese government, especially MOH, has more and more used to invite bioethicists to provide suggestions. After years of discussion, the Ministry of Health (MOH) promulgated in 2001 Technical Regulations of ART, Basic Standards and Technical Regulations of Human Sperm Bank, and Ethical Rules for ART and Human Sperm Bank and revised them in 2003, to regulate the application of such technologies, guarantee their safety and protect the welfare of Chinese people.
Moreover, the legislation in research ethics improved significantly. In 1999, the State Food and Drug Administration (SFDA) published Good Clinical Practice which regarded ethical committee and informed consent forms as main measures to protect the rights of human subjects. It was revised in 2003. In 2007, MOH issued Ethical Review Regulations for Biomedical Research Involving Human Subject. Regulation pointed out that the (at least) five IRB members should have different scientific and nonscientific background. In addition, SFDA published Guidelines for Ethical Review of Clinical Drug Trials in 2010 which illustrated more detailed norms about ethical review of clinical drug and medical devices trails.
Seeking foundation for Bioethics in ChinaGenerally, when facing bioethics issues, most scholars resorted to western bioethics and applied the four principles of bioethics which were widely accepted in western countries, trying to draw some conclusions. However, China is a more community-based or a family oriented society, and respects the collective decisions rather than those of the single individuals, and this makes the situations and concrete problems much more complicated than one can imagine. Moreover, some scholars do not think that the four principles of bioethics are very applicable in Chinese culture and biomedical context, and some theoretical studies on bioethics from the point of view of Chinese culture have been started in recent years. Such discussion has been initiated since the late 1990s.
The development of bioethics in Asia has its own characteristics and it has been seeking a balance between the individualist and communitarian approaches and between rights and duties. The paradigm of bioethics in the West is rooted in an individualist approach which maintains that an individual action pursuing self-interest is rational and that all such actions will converge to favor the interests of society at large (Qiu Ren-Zong, 1996, p. 13).
Asian people have the impression that bioethics is a western product. For instance, when discussing the theoretical foundations of bioethics, western scholars refer to John Mill's utilitarianism and Kant's deontologist view. Are we transplanting these western concepts to Asia? Is there any hidden bioethical thinking in the East waiting to be explored? Can Asians develop a concept of bioethics based on their traditional cultures? (Michael Cheng-tek Tai & Chung Seng Lin, 2001, p. 51).
Among the scholars who tried to develop a Confucian Bioethics, Ruiping Fan is one of the most productive in books and papers. He wrote a paper arguing that Confucianism provides a better approach to healthcare reform.
The Confucian Perspective: Why It Is So Different? The Confucian worldview is grounded in a moral experience of benevolence (ren) cultivated and sustained in rightly directed ritual behavior (li). … Confucian thought has its own cardinal moral concepts such as li and ren. Li identifies proper rituals and ren identifies the realized full humanity, human heartedness, or benevolence required to discipline oneself through proper rituals (li) so that one can become an authentic moral agent and appropriately engage in right action. As the cardinal Confucian virtue, ren is a type of human love naturally rooted in family relations, especially in the parent–child relation (Analects 1.2; Mencius 7A.15; The Doctrine of the Mean 20.5). Confucianism sees the foundation of morality in the cultivation of this natural benevolence and its gradual extension to other people (Analects 12.12; Mencius 4B.28) through the observation of proper rituals (Analects 12.1).…… the Confucian moral point of view does not seek a disinterested regard of individuals, but instead the moral flourishing of families. The values of families cannot be reducible to the total sum of the interests of their individual members. Because Confucian understandings of ren and li are located within the perspective of the family, the profit motive, or, for that matter, the greed that moves many if not most engagements in the classical market, is domesticated by being placed within a benevolent familial context” (Ruiping Fan, 2008, p. 282).
It is worth noting that the bioethics in Taiwan and Hong Kong also experienced rapid progress during these years. Professor Shui Chuen Lee is the leading scholar in Taiwan who initiated the bioethics research. In addition, mainland scholars regularly went to Taiwan to participate in the international seminars on bioethics. In Hong Kong, Ruiping Fan and his colleagues are working together to make an effort to construct the Chinese bioethics by seeking sources from traditional Chinese philosophy and social values. Hong Kong Baptist University founded a Center for Applied Ethics in 1992. So far, the center has organized nine symposiums on Chinese Bioethics Construction and Summer Class on Sino-American Perspectives in Bioethics to provide training for young scholars in China. Fan also published his book Contemporary Confucian Bioethics in 2010 in which he attempts to find a way to establish the framework of Chinese bioethics in the context of Confucianism.
Seeking a Chinese paradigm of ethical foundation will continue, and debate will also continue. Generally speaking, the principles promoted by Beauchamp and Childress are still accepted, yet in application to concrete situations, tradition should not be ignored.
Some characteristics of Chinese Bioethics: truth-telling as an exampleHere is a case. A male patient, whose wife has died, has two adult sons and one adult daughter. The patient has been diagnosed with terminal cancer, there is no cure, but the feasible chemical therapy may be limited to delay his death, and this kind of chemotherapy will produce severe discomfort and pain. The three children believed that their father had a deep fear of death and cancer, so he should not be informed of the diagnosis. Moreover, they believed that the family's responsibility in this case is to refuse to accept the further chemotherapy and thereby, in order to relieve the father of unnecessary suffering, the doctor should accept the family decision.
Confucianism will support the above decision. But, according to Beauchamp and Childress's ethical principles, if the patient is sober, has the ability to act, then respect of his autonomy requires doctors and patient to carry out direct and honest communication. From this point of view, all decisions regarding treatment must be taken by the patient (Fan Ruiping, 2012, p. 638).
The situation in China is: If a patient is diagnosed cancer, usually physicians will be willing to follow the family's preferences not to tell the truth to the patient, though few patients can know the truth by strongly requesting it. A general difference between the western physician and Chinese physician regarding such cases is clear: the western physician would need a special reason to justify not telling the truth to the patient, while the Chinese physician would need a special reason to justify telling the truth to the patient.
From the example above, we can try to conclude on some points characteristic of Chinese bioethics. The first is that beneficence, instead of other principles, is still commonly accepted as the number one principle when dealing with the clinical issues. Patient-centered beneficence is the most important context in truth-telling, where the good and benefits of the patients are interpreted and represented by the close family members under the guidance and suggestion of physicians. As a result, the decision to communicate the truth about a diagnosis or prognosis to the patient depends on considerations of the patient's condition, the likely impact on the patient and the family's wishes in the matter. In a word, the general justification for decision must be the patient's best interests (Fan & Benfu Li, 2004, p. 182).
The second characteristic of Chinese bioethics is the family-oriented autonomy and the familistic model of informed consent. Telling a lie to patients does not mean that physicians do not need to inform anyone, but that informed consent in clinical practice is not given by individual patient, but by the family in China. The family has the responsibility to take care of the sick members, and on the ground of the respect for the patient's will, the physicians take all the opinions of the patient's family members into account. The family is the basic unit of Chinese society. In actual practice, physicians frequently inform the families rather than the patient in clinical decision-making. This stands in contrast with western style where the patient's individual autonomy is more highly respected. This Chinese paradigm of informed consent can be named as the model of doctor-family-patient relationship, instead of the doctor-patient relationship in western countries.
To a great extent, Chinese medical ethics and bioethics are deeply influenced by Confucianism. The central theme of Confucianism is humanness, virtue ethics and deontology. Medicine was then recognized as a humane art which was based on the spirit of loving others. This special non-western idea gives modern health care providers an original perspective to examine everyday practice with patients and subjects. Doctors are responsible to do good for patients. Confucius is one of the most influential thinkers of Chinese philosophy and eastern philosophy. Confucius, together with Socrates, Gautama Buddha, and Jesus Christ were regarded by Jaspers as the four paradigmatic individuals, due to their extended influence through two millennia and their extraordinary and outstanding importance for all philosophy (Jaspers, 1962, p. 6).
Furthermore, family is the basic unit of Chinese society, and the special worship of family valued by Confucianism contributed a lot to form the special physician-patient relationship pattern in China. The relationship between children and parents was taken as one of the foundations for all other special relationships in Confucianism. It was widely accepted that the responsibilities for family members to take care of each other were not only the most important obligations during one's life, but also grouded their loyalty to the emperor in more than twenty hundred years. Nowadays, such family duties and values are still treasured by Chinese people and extraordinarily active in some prominent ethical problems like informed consent and truth-telling when one comes to the context of medicine (Hong-wen, L. & Yali, C. (2008).
In sum, it is said that a special family autonomy in China favors collective decision-making over respecting the will of individual patients, and regards paternalism as being supported by Confucian culture. Chinese people in general are purportedly driven by an interest in what is good rather than in what is right (Fan, 1997, pp. 309-332).
New challenge and reflection on BioethicsIn April 2015, for the first time in the world, Chinese scientists have reported editing the genomes of human embryos. The results are published in the online journal Protein & Cell and confirm widespread rumours that such experiments had been conducted (rumours that sparked a high-profile debate about the ethical implications of such work). In that paper, researchers led by Junjiu Huang, a gene-function researcher at Sun Yat-sen University in Guangzhou, tried to avoid such concerns by using ‘non-viable’ embryos, which cannot result in a live birth, that were obtained from local fertility clinics. The team attempted to modify the gene responsible for β-thalassaemia, a potentially fatal blood disorder, using a gene-editing technique known as CRISPR/Cas9. Huang says that the paper was rejected by Nature and Science, in part because of ethical objections; both journals declined to comment on the claim. It is said that at least four groups in China are pursuing gene editing in human embryos (Cyranoski & Reardon, 2015).
Naturally, some blames will be put on Huang and his team. But when we blame on Huang and his team, we need to consider what bioethics education background they have had on this topic. We need to analyze the cultural background and ethical debate on embryo and its moral position. Some survey showed that many Chinese people do not regard abortion as an ethical issue. This could be attributed to one of our traditional ideas, i.e. that the human life begins just after birth. Another reason is closely combined with the birth control and one child policy in China started in the late 1970s and 1980s. (Cong, 2003, pp. 239-260). So, not only Huang and his team researchers will be puzzled, but also some other groups too. This reminds us to reflect more on the meta-issue of bioethics, and we have to ask: do we have a universal answer? If not, is the existing difference rational and acceptable? Can the issue of whether we can accept or not such cultural difference in the evaluation of the moral position of the embryo continue without further analysis?
Though scholars have set up the basic framework of bioethics in China, initiating the dialogue nationally and internationally, the voice from China is still lacking regarding important emerging issues. It is certainly true that China shares fundamental values, like doing no harm, beneficence, respect and treating patients equally. For Chinese Bioethics, however, it is still an important challenge to find how to facilitate the mutual communication and understanding without raising a sharp ethical debate.
Let us go back to the truth-telling issue. According to Immanuel Kant, every person has the ability to understand the notions of right and wrong and to act accordingly. This does not mean that everyone will agree on what is right nor that, once understood, each person will always do what is right. But we should safeguard the right of every person to make his or her decisions and respect their decisions. In traditional China's context, we can find a totally different theoretical approach. This difference concerns the key issue: between right and good, which takes priority? Applying this question to truth-telling, most physicians in China prefer “good”, instead, most physicians in western countries prefer “right”. And these two approaches seem incommensurable.
Considering this example historically, we can find the changing path from withholding information to disclosure. Personally, I think that, as far as medicine is concerned, there is still some distance for China to go through, from traditional values to modern medical professionalism. This leaves room for the education of future generations of researchers in China. Being bioethicists, we should develop and improve the training in bioethics for future researchers more and more broadly.
Concluding, at the global level, on one hand, we should try to promote our own ethical discourses in bioethics research to cope with some particular problems facing China; on the other hand, being humans, we still need to work together globally to find out common ways and common values that we can treasure, instead of only stressing our special views.