Proposing Asian Principles of Bioethics from Asian Perspectives

Abstract

Principles provide a good guide for any decision-making, either in clinical setting, bioethical consultation, research ethics, even in daily human transactions. The most famous principles in modern times have been the socalled Georgetown principles. European bioethicists under the leadership of Peter Kempt and Jacob Rendtorff proposed autonomy, dignity, integrity and vulnerability as basic ethical principles in European bioethics. Asians have adopted Georgetown’s principles but in their applications, found that in Asia, familial factors have been the basis of decision-making rather than each individual. An individual as a member of family has been regarded as a smaller self to Asians while there is a bigger self, family.

In this paper, the author attempts to advocate a set of Asian principles of bioethics that are rooted in Asian cultures. They are Compassion, Ahimsa (nonmaleficence), Respect, Righteousness and Dharma (responsibility).

Keywords: Principles; Confucianism; Asian ethos; Contextualization

Introduction

Much discussion and debate have taken place after the publication of Principles of Biomedical Ethics, co-authored by Georgetown University’s bioethicists, Beauchamp and Childress who implied that the four principles they promoted reflect not only the common concerns of the world but also are trans-cultural in nature [1]. In other words, these four principles, based on common morality theory, can be universally valid.

At first glance, one cannot but agree with this argument. But on a closer examination, one will notice that these four principles are more western than eastern, let alone universally functional despite the fact that Asian religious and philosophical thought share similar concerns.

The Four Principles of Medical Ethics and Asia’s Confucian Understanding

Biomedical ethics have been guided by a few broad principles, at least from the perspective of principle-ism which, though questioned by some has gradually been accepted by most bioethicists. Some biomedical ethicists list seven, veracity, autonomy, beneficence, nonmaleficence, fidelity, confidentiality and justice [2], but Beauchamp and Childress listed only four and see the other three as derivatives.

Beauchamp and Childress have argued that these principles are trans-cultural in nature, yet Asians have different understandings of their implications. Confucianism, one of the dominate thinking’s in Asia will be selected as an example to illustrate the similarities and differences in the interpretation of these principles.

Nonmaleficence and beneficence

A physician, as stated in the Hippocratic Oath, “Can never use treatment to injure or wrong the sick”, “Primum non nocere - do no harm” hence became the health professionals’ obligation. If a physician cannot benefit someone, at least he/she should do no harm to them. Beneficence is the positive dimension of nonmaleficence. This principle claims that physicians have the duty to help others further their interests. It refers to a positive duty of promoting the health and welfare of patients above all other considerations.

These principles of “do good and do no harm” reflect Confucian teachings. “Do good” is the positive aspect of Jen, the foundation of Confucian ethics. “Do to others what you wish for yourself” is called by Confucius as Chung, or conscientiousness to others. “Do no harm” is the negative aspect -- “do not do to other what you do not wish yourself” which is called Shu, the way to practice Jen [3].

Furthermore, nonmaleficence and beneficence are understood not only as duties but also as inborn natures of man. Mencius, the second sage in Confucianism, believes that all men are endowed with a concern toward others. In his word: “All men have the mind which cannot bear to see the suffering of others” [4]. He further explained: “When I say that all men have the mind which cannot bear to see the suffering of others, my meaning may be illustrated thus: now when men suddenly see a child about to fall into a well, they all have a feeling of alarm and distress, not to gain friendship with the child’s parents, nor to seek the praise of their neighbors and friends, nor because they dislike the reputation of lack of humanity if they did not rescue the child” [4]. From such a case, we see that beneficence and nonmaleficience are expressions of the feeling of commiseration which Mencius asserted as the beginning of humanity. From this, we see that Confucian thought regards beneficence and malificence as more than principles to be promoted. They are part of human nature.

Justice

In its most basic terms, justice may be characterized as fairness which requires that we do not do for some what we are unwilling or unable to do for all. It requires health providers to treat every patient as equal and provides equivalent treatment for everyone with the same problem.

In the Confucian tradition, justice, firstly, is not understood as fairness but as righteousness and oughtness of a situation. Using filial piety as an example, the elders deserve their rights to have the first share in time of destitution. It is not a question of being fair or not, but rather it is a question of oughtness as a respect toward the elderly. The western concept of fairness and equality are missing in Confucian society.

Secondly, everyone in society has certain things which he ought to do. If, however, he does them only because of other non-moral considerations, then even though he does what he ought to do, his action is no longer a righteous one. To use a word often disparaged by Confucius he is then acting for profit. Righteousness and profit are opposing terms in Confucian teachings. Confucius sees justice not so much as fairness but as oughtness of a person to be right. Justice thus to Confucians must be interpreted differently. It is not justice according to needs but justice according to what one deserves.

Autonomy

The origin of this principle can be traced to Kant’s belief that rational individuals should be permitted to be self-determining [5]. Accordingly, no medical decision is made without the participation and consent of patient. Physician and patient are a team. Autonomy means patients’ self-determination. Patients ought to be treated not as children by their physician-parents, but as adults in adult-adult transactions. It requires that patients be respected as equal partners participating in any decision-making affecting their own lives. From this principle we have derived the concepts known as informed consent, truthfulness and confidentiality.

The concept of self-determination is, again, interpreted differently in Confucian teaching. Self-determination cannot be an individual thing but rather a family business [6]. The center of each person’s life is not the individual himself but the family. So if there is any autonomy in Confucian thinking, it is a collective one not a personal one [6]. An individual is but a member of social fabric. A decision must be made within the context of this larger self rather than the individual smaller self. For instance, when a person is diagnosed with terminal cancer, the patient often is not informed but the family member such as husband or elderest son and the consent on how proceed is made by the family members in a collective fashion rather than the individual patient making the decision. Every individual is regarded as a part of larger self, thus the kind of autonomy as understood in the west is missing in the east [7]. This applies not only in countries influenced by the Confucian thinking such as China, Taiwan, Korea, Japan, Singapore and even Vietnam, but the Indian continent also shares the similar view where father or the eldest son in case father being deceased, is the key decision-maker rather than the individual patient. Autonomy that advocates individual right is a strange concept to Asians. It does not mean there is no such thing as autonomy, rather, it is collectively not individualistically understood and practiced.

Biomedical Principles with Asian Ethos

We see similarities and differences between Confucian understanding of bioethical principles and the Georgetown’s. If medical ethics is going to take root in Asia, the principles introduced by western scholars must go through a process of contextualization otherwise those principles advocated by the Georgetown scholars will remain western ones.

Contextualization is a process of making indigenous what is imported from foreign lands to endow it with native spirituality so that it can become culturally acceptable [8]. Although bioethical principles promoted by Beauchamp and Childress have expressed as those of Confucianism based societies, differences exist. The concept of beneficence and nonmaleficence can be easily found in Asian tradition, both in Confucian and Hindu traditions. Confucian societies would understand as benevolence and compassion Jen. In Chinese character Jen is composed of a letter meaning a person and a number two, signifying that benevolence is to be expressed and practiced among people and it is to be done to benefit the other such as “do not do to others what you do not wish yourself”. In Hindu tradition, it is called Ahimsa, the “do no harm”. Those principles advocated by the Georgetown scholars actually are also implicitly hidden in Asian thinking’s. To make sure the spirit of these principles become alive, contextualizing them in the concept familiar to Asian people would be desirable.

Despite the fact that Asia is not homogenous, (containing many different religions and cultures), Asians share a similar ethical framework, and thus the following principles are suggested for consideration:

Compassion

Compassion is not only a Buddhist teaching, but also a Confucian virtue. It is like beneficence stressing the importance of doing good for others. Mencius believes that all men are endowed with a concern toward others, in his own words, “all men have the mind which cannot bear to see the suffering of others….a man without the feeling of commiseration is not a man. The feeling of commiseration is the beginning of humanity…” [9]. Buddhism has taught compassion for all living creatures, animal life, as well as human. Compassion is not directed only toward humankind, it has an impersonal goodwill to all living beings too. Compassion is not based on sympathetic feeling, it is more empathy than sympathy. And this is what bioethical ethics should emphasize, that is the showing of empathy of health professionals toward their patients.

The feeling of commiseration as the beginning of humanity according to Mencius, applies to all humankind including health professionals. When commiseration is felt in medical settings, both health-care providers and patients mutually benefit as the relationship is brought closer together.

Ahimsa or nonmaleficence

Asians have always upheld the idea of non-violence, especially in the Buddhist and Hindu traditions. Ahimsa goes beyond the concept of nonmaleficence to extend “Do-no-harm” to all living creatures. Ahimsa, from the Sanskrit, is normally translated as nonviolence and reverence for life [10]. In practice, it means abstaining from animal food, relinquishing war, rejecting all thought of taking life, regarding all living as akin. This noble thought reflects the idea of nonmaleficence to the point that we should not harm our fellow humankind, or animals. This loving care is to extend to all living beings. This concept can be transformed into a biomedical principle to emphasize the spirit of nonmaleficence. Ahimsa is native to Asians and is unlike nonmaleficence as it which bears a foreign tone. Thus adopting this Ahimsa to promote the idea of do-no-harm will be more far-reaching and effective in the Asian cultural sphere.

In the Confucian tradition, Ahimsa is expressed through filial piety. What we have physically are gifts from our parents and we must safeguard and cherish them. Mencius said “Body and hair are given by our parents, one must not harm them”. It implies nonmaleficence not only to oneself but also to others [7].

Respect

This refers to the respect as found in the spirit of filial piety. According to the Confucian tradition, children are required to pay due respect to their parents and elders. Furthermore, this piety is to be extended to a larger scope of family, where brotherly love is emphasized along with mutual respect required for social dealings. It also implies an informed consent based on family decision-making rather than on individual determination. For instance, the family head or father is usually the one whom the physician consults with in a medical decision-making situation. Individualistic autonomy is weak in Asian tradition. Thus informed consent is done collectively in a family circle. Respect here therefore refers to the rights of the individual as well as the right of the family as a collective unit of individuals. Traditionally, Asians have worked as a collective unit in which the father or the eldest son, when father is deceased, functions as the head of family. Respect is due to this “collective individualistic autonomy”. Although this collectiveness is gradually being reduced by the process of modernization, it remains strong in many parts of Asia. When we talk about informed-consent, we must not negate Asian “collective-individualism”. This respect has a two hold meaning: a respect toward the individual‘s individuality and a respect to the traditional collective individuality. Autonomy thus has to be understood in a larger individualistic context.

Furthermore, this respect also pinpoints to the physicianpatient relationship. Respect implies mutual trust. The lofty work of a physician is highly respected in Asian society. They are not only healers but also advisors in many instances in a village. This kind of privilege should not be taken for granted but rather it should reciprocate to patients in the manner of respect toward patient.

Mencius was once asked if men love their neighbors’ children in the same way as they love their brothers’ children, he answered: “treat the aged in your family as they should be treated and extended this treatment to the aged of other peoples’ families. Treat the young in your family as they should be treated and extended this treatment to the young of other people’s family” [11]. Here Confucian scholars lay the ground for a proper way of treating others and this becomes a good ground for medical ethics principle.

Although we can say that Asian society is very much paternalistic, Confucian teachings indicate that due respect should be given. His concept of respect is also expressed through the idea of righteousness.

Righteousness

Righteousness is an oriental way of expressing justice with a different emphasis from the west. It means the right thing to do as well as doing things right Thus, righteousness and oughtness are standards for moral judgement.

The fundamental basis of this teaching is that one should act according to his conscience without having any desire to gain profit. So righteousness and profit are two opposing terms. When one does things because of the potential profit, it is not righteous and therefore is not just. Confucius thus said: “the superior man comprehends yi; the small man comprehends li “(profit) [12] means that superior man will act according to righteousness while the small man will act because of profit.

Righteousness in Chinese understanding also refers to one’s willingness to sacrifice himself for the sake of a noble cause, such as for patriotism or for filial piety. A person died for such a cause is described as giving up life to opt for righteousness (sur shun tsi yi) or as bravely embracing righteousness when confronted with the situation to make a choice. (Chien yi yiong wei). When one betrays and denies his benefactor who helped or did him good, it is described as forgetting grace to be in debt of righteousness (wong un hu yi). It is obvious that righteousness in Chinese understanding has moral and religious implications. Applying this self-giving righteousness to medical settings, the patient-physician relationship could greatly be enhanced. As from this understanding we can derive that a just physician would try his best to take care of the sick regardless of gain and profit. Can we find any role model in this righteousness principle? Dr. Albert Schweitzer and Sister Theresa were good examples as they had devoted their lives for righteousness sake.

The Asian social habit of gift-receiving or giving can serve as another example to explain this principle. The red Envelope is a traditional Chinese way of wishing someone good luck or expressing gratitude. Usually the gift is money put in a red envelope. The color “red” signifies good fortune. Children receive red envelopes on New Year Day or some special occasions, such as birthdays or weddings. Red envelope is also given to congratulate the recipient for any accomplishments. Without such an envelope the physician will either refuse to take care of the patient or simply purposely extend no care at all in a hospital. A principle of righteousness will warn physicians that this demand is bioethical unjustifiable and unrighteous. Giving care to patients is physicians’ perfect duty, thus receiving gifts is unrighteous and unjust.

Dharma--responsibility

Dharma is a Hindu concept meaning “pattern of right living”. Everyone in his/her social station is endowed with duties which must be carried out. Without following this, disgrace descends on all who flee their duties as illustrated in the Hindu epic the Bhagavad-Gita. In one passage the Hindu deity Krishna answered Arjuna, a warrior who was afraid to fight as a soldier in fear of acquiring karma. Krishna said that real duties of life must not be abandoned. Performing duties of station in life is a service to God thus no karma will be created. On the contrary if a person refuses to carry out his duties, disgrace descends upon him [13].

Applying this dharma to medical settings, taking care of oneself is one’s dharma just like what Mencius said that body, skin and hair…are gifts to us from our parents and we must safeguard them. Any negligence in caring one’s given life is irresponsible and thus is disgraceful. This implies that each person must not abuse their health. It is our inviolable responsibility to take a good care of our body. Failing to do so is irresponsible and thus unfilial.

“Can heavy smokers and drunks have the right to receive hearttransplant when such a procedure is the only way to save them? “This is a question of peoples’ role in taking care of themselves. More and more Asian countries have implemented universal medical insurance to provide equal and free medical service to their people. Some people regard this as a guarantee of their health as medicare is freely available, and thus abuse their own body by drinking excessively or put themselves in physically dangerous situations. After all, they can expect medical treatment to restore their health anyway.

The principle of dharma asserts that each person has a duty to take care of themselves not depending on medical insurance to ensure their health, nor should they take health service for granted. Each person must fulfill his duty of maintaining a good life-style and co-operate with physicians when sick to restore their health.

This principle of duty is also expressed in Confucianism through the concept of the Rectification of Names. Names refer to social stations of each person. When asked what the rectification of names is, the master answered: “let the ruler be ruler, the minister be minister, the father be father and the son be son” [14] meaning that each person should act according to what a person is expected to do in his profession and station in life. Every name contains certain implications which constitute the essence of that class of things to which this name implies. Doing should agree with names. The ruler must bring wellbeing to his subjects, the minister be loyal to his master, the father care for his young and the son filial to his superior. Every name in social relationships implies certain responsibilities and duties. Ruler, minister, father and son are all the names of such social relationships and the individual bearing these names must fulfill their responsibilities: “Between father and son, there should be affection: between ruler and minister, there should be righteousness: between husband and wife, there should be attention to their separate functions: between old and young, there should be a proper order and between friends, there should be faithfulness” [15]. In other words, the person who bears names ought to make sure that his action reflects the requirement of his names. A person, who does so, is a man of Jen. By the same token, a physician must fulfill his responsibilities. His dharma is to care for his patients benevolently and the patient must co-operate with physicians besides dutifully taking care of him or herself.

Conclusion

The four principles advocated by Beauchamp and Childress have indeed expressed some moral concerns of the East, yet their emphases and implications are not quite the same for Asians. This set of principles if based on the Asian ethos may make sense to Asians, and, in turn facilitate the implementation of medical ethics in Asia. These proposed principles are in no way in competition against the western concepts but rather help enrich them so that bioethical globalization can become contextualized to suit cultures across the world. Globalization does not mean universalism, rather it pinpoints to the global and universal endeavor to enhance human dignity and wellbeing for humankind in biomedical settings.

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