CHINESE CONFUCIAN CULTURE AND THE MEDICAL ETHICAL TRADITION

Abstract

     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 comport 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.

As the world strides into the twenty-first century, scholars around the
world are contemplating, forecasting and portraying what the future will be
like. In the next century, what kind of a world will we live in? How will
we work? What moral values shall we need so as to co-ordinate and handle
interpersonal relations and man's relation to society? These questions have
provided much food for thought. One of the most heated debates centres on
medicine, which is a common cause for all mankind, and medical ethics,
which concerns each and every one of us. My topic for discussion is Chinese
Confucian culture and the medical ethical tradition. I will expound on
Chinese Confucian culture and its profound influences on, and the intrinsic
connection with, the medical ethical tradition in China. I will also talk
about the need for re-examining the moral values and ethical standards as
embodied in Confucianism in order to meet the rapid developments in modern
medicine.

I. Confucian culture and its profound influences

In the Spring and Autumn Period (770-476 BC), the slavery society in China
was disintegrating and a new culture was being conceived which would shape
future society. In this extraordinary period of history was born an
extraordinary cultural giant, Kung Chiu, respectfully addressed by later
generations as Kung Fu-tse or Confucius. Confucius (551-479 Bc) was a
distinguished philosopher, thinker, educator and political ethicist in the
late Spring and Autumn Period (1). Although he was of humble origin, he had
an acquisitive mind and a contemplative nature even as a child. He was once
a petty official responsible for running a warehouse and raising cattle.
Then he began to recruit disciples and to give lectures. He was the first
to found a private school in China. Though he later held various
high-ranking official positions in the state of Lu, he was mainly
interested in founding schools, giving lectures and promulgating and
promoting his academic views and political ambitions. Together with his
disciples he journeyed through much of the then politically and
economically developed regions of China. The journey, which lasted fourteen
years, helped him gain a deeper understanding of the then prevalent
academic viewpoints and political beliefs of various schools as well as of
social reality, through cultural exchange and observation. A unique school
of Confucianism, which exerted immense influences on the thinking, culture
and political life of ancient China, was established by Confucius as he
made his profound inquiries into philosophical, ethical, political and
educational problems.

Concept of 'conscience'

After the death of Confucius, his disciples inherited and developed his
academic thoughts. Mencius (circa 390-305 Bc), leader of one of the eight
minor schools of thought developed from Confucianism, politically advocated
the kingly way and opposed the way of might, and placed moral value on
righteousness and despised profits. He was the first to formulate the
concept of 'conscience' in the history of Chinese ethics and he was
regarded by later generations as the true inheritor of Confucianism.
Tsun-tse (circa 313-238 BC) criticized all other contending schools of
thought and only revered Confucianism. Ethically, he concretized the
concept of 'morality' and raised the possibility that 'man is born evil' as
opposed to the hypothesis of Mencius that 'man is born good' (2).

In 213 BC, a well-known event in China's history took place. Emperor Qin
Shihuang, who was offended by the political viewpoints of Confucian
scholars, ordered the burning of classical writings of Confucianists and
the killing of over 460 Confucian scholars. The tragedy dealt a heavy blow
to the school of Confucianism and arrested its development for some time.

In the Han Dynasty (206 BC-220 AD), the importance of the school of
Confucianism's tendency to support those in authority, such as monarchs,
was recognised; Confucianism was for the first time crowned as the national
orthodox culture when Emperor Han Wudi issued the decree 'to ban all other
schools of thought and to sanctify Confucianism'. Confucian scholars in the
period, as represented by Dong Zhongsu, adapted Confucianism to form
philosophical theory about rulers. This promulgated the concept of 'the
unity of heaven and man' and supported absolute monarchy (3).

During the Tang Dynasty (618-907) we saw the emergence of Taoism and
Buddhism as rivals to Confucianism. Confucianism further developed in the
process of both rejecting and absorbing Taoism and Buddhism. Han Yu et al
tried to adapt Confucianism into a religious belief but failed (3) while
other scholars developed the early Confucian thinking of 'valuing people
and loving people'. In the interim, Confucianism was beginning to be merged
with natural sciences and medicine.

In the Song (960-1279) and the Ming (1368-1644) dynasties, Confucianism
appeared in the form of 'Confucian idealist philosophy' out of the fusion
of Confucianism with Taoism and Buddhism, which later became the dominant
philosophy of rulers in late feudal society (960-1840) in China. These
scholars were mainly concerned with the philosophical problems of human
nature find the way of heaven and propounded the extreme proposition of
'letting the heavenly principles live and letting human desire perish'.
Feudal rule in China became more oppressive spiritually. These scholars
also made great efforts to annotate classical Confucian writings and
consolidated the concept of 'national character' and the Confucian ideal of
a prosperous state and a humanitarian world. No noticeable development in
Confucianism occurred after the Ming Dynasty.

Confucian culture by this time was extensive and wide-ranging, embracing
the social, political, cultural, educational, ethical and moral aspects of
life.

According to Confucian thinking, the ruling class should learn the merits
and virtues of Yao and Tsun, who were legendary monarchs since time
immemorial in China (22nd-21st centuries, BC) and imitate Emperors Zhou
Wenwang and Zhou Wuwang (circa 11th century BC), two outstanding emperors
of the Zhou Dynasty, in the way of governing the state. Confucianists
endorsed 'ritual' and 'goodness and justice' and advocated 'ruling by moral
force' and 'ruling by ritual'. Confucius said: 'If you rule the people and
keep order among them by punishments . . . they may avoid doing what is
wrong, but they will also lose self respect. If you guide the people by
moral force and keep order among them by ritual, they will keep their self
respect and come to you of their own accord' (4). Mencius inherited
Confucius's concept of benevolent government and promoted the kingly way of
ruling people by goodness and opposed ruling people through might.

Profound implications

Confucian culture is not just one academic school of thought, it has.
profound connotations and implications. What is more important is that
Confucius inaugurated philosophical study in China and it can be said that
he is the first great philosopher in China's history. He started academic
debates of a philosophical nature on man's destiny versus human efforts; on
rule by benevolence versus rule by law; on the innate goodness or evil of
human nature; on the process of knowledge acquisition; on methods of
self-cultivation, and on other contentious topics. Confucianism is
basically idealistic in nature, though among distinguished Confucian
scholars of various dynasties one can always find some who were
materialistic.

It is believed by Confucian scholars that education, especially moral
education, plays a decisive role in ruling and keeping the state healthy,
and that men can become knowledgeable, sensible and capable through
education. Not surprisingly, Confucius started a private school with over
3,000 disciples. Some Confucian education theories about methods of study
and scholarly research remain useful to later generations.

Social order

In Confucian culture, the importance of social ethics and morality is also
highly emphasized and instruction in ethics and morality is integrated with
politics. Thus, a special and unique unity of politics and ethics has
formed. It is held that political rule should be supported by instruction
in ethics and that each and every principle and norm of ethical instruction
should be adapted so as to meet political needs. Therefore, Confucianism
has become a school of thought which teaches rulers how to rule and the
common people how to abide by that rule and behave properly - the aim being
to maintain the social order which was based on hierarchy.

The essence of Confucian culture, either from the perspective of history or
from that of reality, lies in its ethical and moral theory. Confucius
formulated a unique system with 'goodness' as the nuclear core confirmed by
'rites' and advocated the idea of 'guiding the people by moral force and
keeping order among them by ritual'. Goodness as the highest moral standard
in Confucianism has dual meanings: an intense concentration of Confucius's
'political thinking', representing Confucius's hope that the ruling class
may 'rule by benevolence', and the high realm of Confucius's moral
cultivation, showing his hope that people may be 'benevolent'. To practise
'goodness' lies in the loyal way: 'you yourself desire standing, then help
others to get standing. You yourself want success, then help others to
attain success', and in the tolerant way: 'never do to others what you
would not like them to do to you' (the 'golden rule' of western
philosophy). Confucius attached great importance to moral education and he
considered that people showed little difference from one another when born
and that only education differentiated individual from individual.
Therefore, he recommended that moral education be used as the foundation of
ruling a state and emphasized the notion of 'rescuing people by moral
power'. Just as Professor Luo Guejie, a well-known Chinese ethicist pointed
out, at the time when ancient Greek thinkers claimed openly that slaves
were only tools that could speak, Confucius in China explicitly formulated
the concept of loving people as 'the most fundamental and the only moral
principle' (1). This is of great significance in the development of human
civilization.

'Ritual', a category rich in connotations in Confucian culture, includes
anything from rites to moral principles and from political systems to legal
principles. But, in the commonest sense, 'ritual' mainly refers to the
extensive system of moral principles corresponding to 'goodness'. The
relation between 'goodness' and 'ritual' is that 'goodness' is the soul of
'ritual', 'Goodness' is the moral standard to be attained by 'ritual', and
'ritual' is the expression of 'goodness'. The former is subordinate to and
serves the latter.

The ethical and moral theory of Confucianism stresses man's spiritual realm
and holds that the moral demand is man's most pressing demand. Mencius
regards morality as the biggest difference between men and animals and he
ridiculed those who were well fed, well dressed and lived in splendid
surroundings but lacked moral cultivation, as showing hardly any difference
from animals (5,6). Confucianists also emphasized the methods of moral
education. Confucius himself stressed 'self-restraint', 'introspection',
'self-respect' and 'self-blame'. Zeng-tse, the chief of another school of
thought, said, 'I inspect myself three times daily'. Mencius also upheld
cultivation of one's moral character. It can be seen that Confucian
scholars consistently endorsed the enhancement of moral character by
self-inspection and self-restraint.

Zhang Zhai (1020-1077 AD) succinctly summarized the goal of Confucianism:
to set rules and laws for the state, to set morality for the people, to
inherit the cultural achievements of ancient sages and to seek eternal
peace under heaven. These features of Confucianism met fully the needs of
feudal rulers. Therefore, Confucianism was reverenced as the nation's only
orthodox school of thought in various dynasties from the time of Emperor
Han Wudi (140-87 BC) and penetrated all walks of life in ancient society.
Confucianism developed a series of deep-rooted concepts in the thought,
consciousness and customs of people, becoming the mainstream culture and
defining people's thoughts, words and acts, and playing an important role
in China's history, unparalleled by any other school of culture (7). It was
involved in the whole process of creating the culture of feudal society and
defined the tone and pattern of feudal China's social thoughts and culture.
The impacts of Confucian culture have to be considered if one wants to know
ancient China and study modern China.

II. Chinese medical ethical tradition and its relation to medicine and
Confucianism

There are some legendary stories praising physicians for their morality
before the time of recorded words.

One of the most notable stories is about the ancient Emperor, Shennong, who
tasted a hundred kinds of herbs and was poisoned 70 times one day. The
story shows that in ancient times our ancestors were willing to sacrifice
themselves in order to save lives and develop medicine. Records of ancient
medical ethics can be dated back to the time prior to the formulation of
Confucianism. In the Zhou Dynasty 3,000 years ago, the skills and the moral
character of physicians were examined annually and physicians were treated
differently, according to their examination results (8). After the
establishment of Confucianism, its ethical and moral concepts exerted
profound influences on medical workers of various dynasties and played a
dominating role in the development of Chinese traditional medical ethics.

Craft of saints

First, there were some distinguished physicians who advocated medicine and
opposed witchcraft. For instance, Hippocrates's contemporary, Bian Que (5th
BC), a famous physician in the Warring States Period (475-221 BC),
formulated guidelines for practising medicine in which he proposed to trust
in medicine rather than witchcraft. He saw as a realistic goal, the
elimination of the harms of sorcery through the construction of medical
ethics. Medical ethics were also emphasized in the famous traditional
Chinese medical classic The Yellow Emperor's Canon of Internal Medicine
(9), in which it is pointed out that medicine is the craft of saints, and a
noble profession and that medical workers should have noble moral
character. The book also enumerates five types of fault and four types of
error in medical treatment and physicians are warned against these faults
and errors. For example, physicians are required to practise medicine
scientifically. It is also stressed that 'one who believes in ghosts or
gods cannot be said to be benevolent' (8). For ancient physicians,
advocating science and opposing superstition was one of the important
aspects of medical moral character, which was highly appreciated by ancient
physicians and in ancient medical writings.

In the following 1,000 years from 500 BC to 500 AD, serious inquiry was
made into problems such as the purpose of medicine, style of work, and
moral character cultivation. Many precious writings on medical ethics were
handed down. Zhang Zhongjing (circa 150-219 AD), a famous physician of the
East Han Dynasty, who was regarded as a 'medical saint', said that his
purpose in learning and practising medicine was to cure rulers and their
relatives of illness, to relieve the common people of distress, and to
promote health and prolong life (8). In his book, Treatises on Febrile
Diseases, he harshly criticized irresponsible physicians by pointing out
the harm and hazard of malpractice among physicians who did not diligently
improve medical skills, who followed the beaten path, who practised
medicine without care and who prescribed medicine rashly for patients.
Benevolence, honesty and sagacity were also regarded by some as important
aspects of physicians' moral cultivation. Dong Feng (3rd century AD), a
famous physician in the period of Three Kingdoms, 'treated people without
any charge. Five apricot trees were to be planted when one was cured of a
serious illness and one apricot tree was to be planted when one was cured
of a minor disease. Several years later, a forest of 100,000 apricot trees
appeared'. Each year, apricots were exchanged for grains which were
distributed to the poverty-stricken. Over 20,000 people benefited from his
generosity each year (10). The phrase 'warm spring in the apricot wood' has
since been used to praise the noble moral character of a physician (8).
Yang Quan, a physician of the Jin Dynasty stressed that a physician must be
benevolent, sensible and honest and must have a noble character as well as
excellent skills. the periods of great prosperity in ancient China. The
time was ripe for summarizing the medical ethical tradition in the context
of political, economical and cultural development. Tsun Simiao (581-682
AD), a famous physician and pharmacist, was an important pioneer in the
field of medical ethics in ancient China. One of the articles in his
important book, Golden Essential Recipes, is the earliest and most famous
monograph on medical ethics. He annotated the title of the book by saying
'human life is more precious and valuable than a thousand gold pieces and
one good recipe prescribed can be life-saving; therefore, the name of
Golden Essential Recipes is chosen'. The medical ethical thinking of Tsun
Simiao was highly appreciated by both Chinese and foreign scholars. A
Japanese professor once remarked, 'Today we talk about respecting human
life. Thirteen hundred years ago, Tsun Simiao in ancient China explicitly
pointed out the truth and wrote about it' (11). The only copy of the North
Song Dynasty (960-1127) version of the Golden Essential Recipes is
carefully preserved in Japan and is regarded as 'a national treasure' by
the Japanese government. In his famous monograph on medical ethics, Tsun
Simiao set the norm for scholarly attitudes, style of medical practice,
character cultivation, deportment and academic ethics. It can be seen from
Tsun Simiao's systematic summarization, and from his contribution, that
Chinese traditional medical ethics was at that time entering a period of
maturity and stability.

Principles of medical ethics

During the Ming Dynasty (1368-1644), efforts were made to set up principles
of medical ethics. Li Shizhen (1518-1593) can be said to have provided the
model of integrity in medical and medicinal studies with the re-writing of
his book, Compendium of Materia Medica. He showed his respect for the work
of others by giving references to the original literature. Gong Jingxian in
the 16th and 17th century enumerated 'ten tenets for physicians and ten
tenets for patients' so as to co-ordinate the relationship between
physicians and patients. His contemporary, Chen Shigong (1555-1636) put
forward Five Commandments and Ten Tenets for Physicians (12), which is
similar to present-day ethical principles for physicians.

In the Ming and Song Dynasties, some physicians were also critics of
medical ethics. They criticised harmful tendencies in medical practice,
thus demonstrating that medical ethical criticism has long been present in
the construction of Chinese traditional medical ethics.

Throughout China's long history, a rather highly developed system of
Chinese traditional medical ethics has emerged with well-defined basic
contents. These lay down that all medical workers should abide by the
following six tenets.

Value of human life

First, they should appreciate the value of life and rescue the dying and
heal the wounded by all means available to them. A lofty concept of the
value of human life was established among ancient physicians, as reflected
in Tsun Simiao's remark that 'human life is more precious and valuable than
a thousand gold pieces'. Tsun Simiao was also determined to relieve all
human beings from suffering, showing his sense of responsibility in
rescuing the dying and healing the wounded. Gong Tingxian of the Ming
Dynasty also pointed out that 'medicine is for living people' and that 'in
a physician's hand lies the life or death of a patient'.

Second, they should care for patients' suffering and practise medicine with
honesty. Tsun Simiao maintained that a physician should bear the suffering
of patients in mind, not his own material interests. In Five Commandments
and Ten Tenets for Physicians, Chen Shigong also asked physicians to
practise medicine with integrity: they should not replace precious herbal
materials provided by the family of the patients with inferior ones, nor
charge the poor, and wandering monks. And what is more, he urged physicians
to give as much financial support as possible to poverty-stricken patients,
for he believed that no medicine could cure any person with an empty
stomach. He also suggested that physicians should not be extravagant but
should live simply. He held that it was much better to save money than to
charge more fees.

Third, they should diligently improve medical skills and oppose careless
styles of working. The Yellow Emperor's Canon of Internal Medicine pointed
out that physicians 'should be knowledgeable about heaven, earth and man'
in order to be qualified doctors. Famous ancient physicians such as Zhang
Zhongjing, Tsun Simiao and Li Shizhen were all diligent in studying
medicine and they were not afraid of difficulty and hardships. Tsun
believed that a physician should concentrate thoroughly and be most
careful, and absolutely accurate, when diag-nosing a disease.

Fourth, they should act with decorum, decency and politeness. The Yellow
Emperor's Canon of Internal Medicine requires physicians to 'ask about the
customs when entering a foreign state, ask about things forbidden when
visiting a household and ask about manners when practising medicine'. This
shows that the good tradition of respecting. customs and practising
medicine with integrity has been stressed since ancient times. In Rules and
Regulations for Practising Medicine, Li Yan of the Ming Dynasty wrote:
'when diagnosing a woman, an immediate relative of hers should be invited
to question the woman about signs, the tongue and dietary habits first',
and 'more respect should be paid and more caution should be given when one
gives medical treatment to a widow or a maid'. In Five Commandments and Ten
Tenets for Physicians, Chen Shigong pointed out that a prostitute who came
to see a doctor should be treated as if she was a good lady and the
physician should not take liberties with even such a woman. These moral
requirements showed the tradition of respect for patients, especially for
woman patients, by physicians in ancient China.

Fifth, they should acknowledge that all patients are equal before a
physician. This concept was significant and progressive in a hierarchical,
feudal society. In The Integrity of a Respected Physician, Tsun Simiao
stressed that patients coming for treatment, whether rich or poor, old or
young, beautiful or ugly, close or distant and Chinese or foreign, should
be treated the same as an immediate relative or a good friend. Gong
Tingxian also criticized doctors who only liked to give treatment to the
rich and neglected the poor, for acting contrary to the purpose of
medicine.

Sixth, they should respect other people's achievements and abide by
academic ethics. Tsun Simiao said a physician should not be conceited and
arrogant. In the Compendium of Materia Medica by Li Shizhen, The Medical
Secrets of an Official by Wang Tao, and Classified Materia Medica by Tang
Shenwei, good examples to fellow physicians were set out. In Five
Commandments and Ten Tenets for Physicians, Chen Shigong also warned
against arrogance and slandering and endorsed humbleness, caution, respect
and tolerance. As it was customary in feudal China that people of the same
occupation despised one another, these moral requirements showed the great
courage of physicians in pursuing medical ethics.

Unique structure

Confucianism occupied a longstanding dominant position in ancient China
and, moreover, 'from its goal, function and structure, it can be said to be
a school centred around ethics and morality' (1). It certainly exerted
immense and profound influences on the development of medical ethics in
ancient China.

Its influences are mainly and fundamentally positive.

First, the school of Confucianism established a unique structure of moral
principles with goodness as the nuclear core confirmed by rites. This
system did not only exert immense influences on Chinese culture, which was
then in the process of civilization, but also served as the keynote of
Chinese traditional medical ethics. In ancient China, medicine was called
'the craft of benevolence' or 'the craft of saints', representing the hope
that physicians would act by the Confucian concept of 'benevolence' and
practise medicine by the teachings of Confucian saints. Various rules and
regulations of medical ethics contained instructions such as: 'Be
benevolent and Confucian' and 'First know the logic of Confucianism and
then the logic of medicine'. These show that physicians regarded it as
honourable to know and follow Confucianism. In The Analects of Confucius's
Fellow Villagers, it was recorded that Confucius's stable was burned down.
Upon learning of the event, Confucius first asked if anyone was hurt rather
than asking about the horses. This story has progressive significance in a
society where a horse was worth five slaves. Humanitarian ethical thinking
as embodied in the theory of Confucianism exerted a direct effect on the
concept of the value of human life and human dignity. Physicians of various
dynasties all stressed that physicians must be benevolent and that the
purpose of practising medicine was to rescue the dying and to relieve the
distressed. These principles have become guidelines for the practice of
medicine. In practice, physicians of various dynasties all regarded it as a
lofty goal to be 'a respected physician of the multitude' and to 'relieve
all human beings from suffering'. It can be said that in ancient China,
only physicians had the highest and noblest professional morality and there
were many folk stories praising the deeds and morality of physicians. All
this is thanks to the influence of Confucian humanitarian ethical thinking
on traditional medical ethics.

Traditional medical ethics concerning the concepts of justice and benefit
were also profoundly influenced by Confucian thinking. The Confucian
concept of 'justice before benefit' requires doctors to give justice
priority and to regard honesty as a duty. To give justice priority means to
regard saving and treating others as one's destined duty. As Chen Shigong
pointed out: 'man receives orders from heaven and should not act
otherwise'. Secondly, physicians should have a self-sacrificial spirit.
Tsun Simiao said in effect that one should devote oneself to the treatment
of patients and should not shun difficulties and hardships and should not
consider one's own loss and gain. Moreover, the 'justice and benefit'
concept of Confucianism instructed doctors to be honest and pure and not to
seek material gain. Under the influence of such thinking, many doctors
regarded practising medicine as a charitable activity and worked without
seeking fame or benefit. The low price of herbal medicine and acupuncture
for relieving pain demonstrated a humanitarian concern aimed at ensuring
that the common people had access to medical resources.

Maintaining a proper relation between physicians and patients has been
consistently emphasized in Chinese traditional medical ethics, which was
deeply influenced by the Confucian concept that 'man is born good'. In
 classical Confucian writings, Confucius outlined a series of principles
and norms for showing respect for, and sympathy to, people, based on an
appreciation of human values and human dignity. For example, 'Never do to
others what you would not like them to do to you', and 'People within the
four seas are all brothers', and 'A noble man helps others to carry out
only their good wishes, not their evil ones'. These philosophical teachings
penetrated the hearts of everyone in ancient China. These teachings require
that physicians show respect for patients and that patients should choose a
sensible physician and comply with the physician by taking the medicine
prescribed. Patients are also asked to receive treatment as early as
possible and to believe in medicine rather than witchcraft. A good
physician-patient relation will be formed with respect and care for
patients by doctors and reliance on, and compliance with, doctors by
patients. Tsun Simiao asked doctors to regard the sufferings of patients as
their own afflictions and to treat patients with profound sympathy.

These attitudes of 'thinking about patients and thinking for patients' are
a further application and development of Confucianism in medical ethics and
provide an emotional basis for establishing satisfactory physician-patient
relationships.

Moral education

The emphasis placed by Confucianists on moral education and moral
cultivation also has direct relevance for the promotion of traditional
medical ethics and the enhancement of physicians' moral cultivation. Many
writings were available on ancient medical ethics which held that by
learning Confucianism one knows the truth and by knowing the truth one
becomes a good physician. In other words, Confucianism teaches people to
promote moral character by self-cultivation, which is also beneficial to
the construction of medical ethics. In ancient China, there were many
examples of individuals who were both famous physicians and famous
Confucianists. The Integrity of Respected Physicians by Tsun Simiao was not
only regarded as a classic on medical ethics but also as representative of
Confucian writing on ethics. Famous physicians in ancient times usually had
great virtue. They taught their students how to be upright men before
instructing them to become physicians; this almost became a set pattern in
the history of the development of medicine in China. All this demonstrates
that the moral pursuit of medicine and Confucianism is consistent and that
this consistency is deeply rooted in the Confucian tradition, which
emphasizes moral cultivation and stresses spiritual pursuit.

Though Confucian culture has exerted positive influences on the development
of Chinese traditional medical ethics, it also has its historical and class
limitations, which adversely influenced traditional medical ethics. For
example, in the long process of history, Confucian culture intensified the
concepts of hierarchy, loyalty and filial obedience. These Confucian
concepts caused some unscientific and unreasonable norms and beliefs to
spring up in traditional medical ethics. For example, Confucianism
over-emphasized the value of human life and was overcautious about contact
with the other sex. The Book of Filial Obedience said that each and every
part of the human body is contributed by the father and mother and no
damage or injury should be done to it. As a consequence, it was held that
surgery and autopsy were immoral. Moreover, the superior position of men
over women and the concept that private contact between men and women was
deemed improper were strengthened by the development of Confucianism. Some
medical ethical regulations stipulated that a woman without company should
not be treated and that a physician treat his women patients over a
curtain. These rules were neither advantageous to women nor convenient for
physicians. Indiscriminate pursuit of 'goodness' can only lead to actual
'evil' and as a consequence, the norms of medical ethics may be
unscientific (13). Furthermore, some Confucian scholars took the concept of
'valuing righteousness and despising benefit' to an extreme. Such Confucian
sayings were often quoted as: 'Great men pursue moral principles rather
than food . . . and worry about moral principles rather than poverty', and
'Great men pursue what is right; petty men pursue what is profitable'.
Righteousness and benefit, and moral value and material interest were set
against each other. As a result, goals were often unreachable and norms
were often contradictory in medical ethics. Finally, the Confucian
tradition of moral education and spiritual pursuit was developed into an
idealist philosophy during the Song and Ming Dynasties which reduced the
practicality and applicability of traditional medical ethics.

III. The role of Confucian culture in the construction of modern medical
ethics

From the perspective of history, Confucianism is neither a static system
nor a meaningless antique in the contemporary world. It is an open system
that moves forward with social development. In Singapore, Confucian moral
education is systematically being carried out under the leadership of the
government. Some Japanese enterprises also appreciate the role of
Confucianism in improving business operations. In the Selected Works of Mao
Zedong, Confucian sayings were quoted over 50 times. These examples clearly
demonstrate that correct evaluation of the position of Confucian culture in
our history, and separation of the essence from the dross in Confucianism,
are of significance in the construction of spiritual civilization as well
as in that of medical ethics.

At present, with the rapid development of modern science and technology,
new methods are created and new wonders are wrought in medicine, but these
also bring about new contradictions in medical ethics. Are our efforts to
enhance the quality of life by modern reproductive techniques worthwhile?
Is euthanasia for patients with terminal illness appropriate? Do the new
techniques such as artificial fertilization, test tube babies, organ
transplantation, behavior control and genetic engineering pose challenges
to human dignity? These problems have posed dilemmas for many concepts of
traditional ethics. With the achievements in biological engineering, man is
once again put in a perplexing situation (13). Many traditional ethical
concepts are being reviewed and many new notions have come into being. Jean
Davies, Chair of the World Active Voluntary Euthanasia Association,
remarked during her visit to our university that: 'Man's thinking is ever
changing. My grandmother's contemporaries talked about money; my mother's
talked about sex and ours are now beginning to talk about death'. How to
keep continuity by inheriting and perpetuating the essence of traditional
medical ethics and how to renew medical ethics is a very serious question.
Confucian culture, which has played an immensely important role in the
formation and development of traditional medical ethics, also needs
objective appraisal and amendment so that Chinese ancient culture may play
a proper role in the construction of modern medical ethics. Four things
need to be done.

1. The Confucian tradition which emphasizes moral education and moral
cultivation should be modernized and promulgated so that people may be
strengthened by the concept that the construction of spiritual civilization
should be highly regarded in a materially developed civilization. As part
of the construction and formulation of medical ethics, laws and regulations
should be drawn up and noble moral character as shown by physicians in
practising medicine should be endorsed, while misconduct should be
disciplined or punished. Medical ethical education and practice and medical
ethical evaluation should be integrated into the framework of medical
education and medical practice.

2. The Confucian concepts of benevolence, righteousness and benefit, human
value and filial obedience, which show historical limitations, need to be
reconstructed. The essence of these concepts which will promote the
development of medicine and help co-ordinate interpersonal relations should
be kept, so that Confucianism can serve medicine and the ancient can serve
the present. In the process, we should note the differences or
contradictions in many Confucian concepts and make suitable explanations.
For example, according to Confucian culture, active euthanasia is not
benevolent and passive euthanasia is not good. If we look to the future and
renew Confucian concepts about the value of human life and benevolence, it
will be helpful in renewing people's ideas and thinking.

3. Such Confucian concepts as nobles being superior to the common people
and men superior to women, should be completely discarded so as to adapt to
social progress and development in medicine. In some remoter parts of
China, negative ideas about birth and mysterious notions about sexual
medicine are related to outdated notions in Confucian culture.

4. We should learn from fellow scholars in foreign countries. We ought to
introduce new medical ethical theories into China. We should also attach
importance to: the enhancement of the quality of life; how best to
safeguard the environment, and the need to carry out investigations into
the difficult medical ethical problems arising from high technology.
Moreover, the medical legal system, the supervising system and punitive
measures should be in keeping with international norms. This will be a
great help in the construction of Chinese modern medical ethics as well as
in the reforming of the health system.

Key words

Confucian ethical tradition; Chinese traditional medicine; modem medicine.

References and notes

(1) Luo, G. A study on Confucian ethical thinking. Literature and history
1988: Jun.

(2) Luo, G. Annotation of ethical terms. Beijing: People's Publishing
House, 1986.

(3) Zhang, C. Historical evolution of Confucianism and its functions.
Journal of philosophy and sociology 1988: Jan.

(4) Wen, K. On the ethical thinking of Confucian humanism. Journal of
Tianjin University 1987: Feb.

(5) Zhang, G. Pros and cons of theories on benevolence and benefit of
Confucianism, Mohism, Taoism and Legalism in early Qin dynasty. Xinhua
reader's digest 1992: Jan.

(6) Qu, Y. On Mencian viewpoints of value. Xinhua reader's digest 1992:
Sept.

(7) Zhong, Z. Confucianism in substitution for religion. Xinhua reader's
digest 1992: May.

(8) Encyclopedia of Chinese medicine: history of medicine. Shanghai:
Shanghai Science and Technology Publishing House, 1987.

(9) According to the Encyclopedia of Chinese medicine: history of medicine
(see reference (8): 167), an American named I Veith got his doctorate
degree by virtue of having translated The yellow emperor's canon of
internal medicine (1949). Scholarly works like World outlook and principles
concerning astronomy, universe, physics and philosophy of the Chinese by a
British man named Alfred Forke (1925), Chinese medicine by an American
named William Morse (1934), and Plain questions - basics of Chinese
medicine, by another American named M Dawson, all refer to the contents of
this great book.

(10) See reference (8): 88.

(11) Sun, P. Master pharmacist Tsun Simiao. Shaanxi People's Publishing
House, 1983.

(12) Guo, Z. New edition of medical ethics. Lanzhou: Lanzhou University
Press, 1988.

(13) Guo, Z, et al. An outline of medical ethics. Shaanxi Science and
Technology Publishing House, 1991.

~~~~~~~~

By Guo Zhaojiang, The Fourth Military Medical University, Xian, Shaanxi,
China

Guo Zhaojiang is Professor in the Political Department at The Fourth
Military Medical University, Xian in The Peoples' Republic of China.
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