Eye on religion: Confucianism, autonomy and patient care.

Chinese culture can be represented by two dominant philosophical traditions, Confucianism and Daoism. Both have focused their efforts in delineating Dao in a different sphere: Confucianists are concerned primarily with the proper way an individual should conduct his life in the social context, while Daoists are devoted to searching for the optimal way in which an individual can live a personal life in harmony with cosmological and nature spheres. (1) The naturalistic thinking of Daoism greatly influenced the healing philosophy of Chinese medicine, while Confucianism has since the Han Dynasty (206BC to 220AD) become the dominant ideology in Chinese philosophy and has directed social, political, educational, and moral thoughts in Chinese and East Asian societies. Chinese medical ethics also was established on the foundation of Confucian ethics, (2) and is important in the physician-patient relationship.

Basic Concepts of Confucianism

The basic concepts of Confucianism can be concisely delineated as follows:

1. The merging of self-cultivation and social-political reform: Confucius believed that political order must be established on social order, and social order must come from individual cultivation. Therefore he said, "Their hearts being rectified, their persons were cultivated. Their persons being cultivated, their families were regulated. Their families being regulated, their States were rightly governed. Their States being rightly governed, the whole kingdom was made tranquil and happy." (3)

2. The pursuit of dao: Dao generally means road or path, method, way, doctrine, the truth or moral teachings. It has been interpreted as the supreme metaphysical force that exists everywhere in everything and dominates the exercise and function of all things in the universe, (4) as well as the universal moral order and the ideal status of moral achievement for man to define, pursue and accomplish. (5) It is "an all-encompassing state of affairs embracing the 'outer' sociopolitical order and the 'inner' moral life of the individual." (6) Humankind should seek the comprehension and pursuit of life in accordance with dao.

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3. The ethical system of jen (humaneness), yi (righteousness), and li (rules of propriety): Confucius' teachings of jen, yi, and li comprise the most fundamental thought and principles in Confucius' ethics. Jen has been translated as love, benevolence, humanity, human-heartedness, virtue, perfect virtue, true manhood, and humaneness; it also signifies the ideal relationship between persons. Yi generally means righteousness, appropriateness, obligation and justice, and is "the principle of setting things right and proper." (7) Li indicates ceremony, rites, decorum, courtesy, etiquette, rules of propriety, and at first represents the ceremonial order, but in the full sense connotes the sociopolitical order. (8) Jen and yi could be said to be the inner core of morality that motivates and guides man to pursue the dao, and li could be described as the outer form and standard of morality that is concrete for man to abide by in the context of human society.

4. The moral ideal of chun-tze (the superior man or gentlemen): Chun-tze is the man of high moral achievement who constantly tries to improve and cultivate himself to achieve various stages of perfection. (9) The moral character of Chun-tze demonstrates both the qualities of "an autonomous person," which includes self-activation, self-determination, self-reliance and self-cultivation, and "a relational person," who is committed to others regarding morality and altruism. (10) The ultimate concern and self-realization of a Confucian ideal person consists in giving security and peace to people, yet to achieve this goal one must become a chun-tze first, which requires incessant moral self-cultivation. (11)

5. The wu-lun (five basic human relationships): Confucius stresses family values and filial piety through articulating the five basic human relationships, "which govern the relationship between ruler and minister, between father and son, between husband and wife, between elder and younger brothers, and those in the intercourse between friends." (12) The wu-lun gave form to Chinese society and social institutions from government down to interpersonal transactions and has far-reaching influence on the East Asian, Confucian ethics-based cultures. Confucius believes good family breeding naturally leads to good social intercourse. (13)

Confucianism was developed in an epoch of chaos aiming at restoring social order and promoting general welfare through everyone's moral self-cultivation and fulfilling one's role-specified responsibilities. Searching to enhance public interest has always been a central theme and fundamental moral value in Confucianism.

Autonomy and Persons

Modern medical ethics is hugely dominated by an approach to bioethics, which was generally developed from the "Belmont report" and Beauchamp and Childress' "The four principles approach to bioethics." While "promoting the best interest of the patient (beneficence and nonmaleficence)" remains the unchanged core of medicine, the values, preferences, wishes, and self-determination (ie, autonomy) of the patient determine what is beneficial from what is harmful in this approach.

Confucianism sees persons and their autonomy differently. As Fingarette says, "man is not an ultimately autonomous being who has an inner and decisive power, intrinsic to him, a power to select among real alternatives and thereby to shape a life for himself. Instead he is born as 'raw material' who must be civilized by education and thus become a truly human being." (14) Liang indicates, "In the Chinese thinking, individuals are never recognized as separate entities; they are always regarded as part of a network, each with specific role in relation to others." (15) "Self" in the classical Confucian sense is both a center of relationships and a dynamic process of spiritual development (16): "one becomes fully human through continuous interaction with other human beings and that one's dignity as a person depends as much on communal participation as on one's own sense of self-respect." (17) Therefore, self-individuation is possible only through a process of engagement with others within the context of one's social roles and relationships. (18)

Moreover, the boundary between self and others in Confucianism is not always clear. The self, as the center of relations, is not merely the privatized self of a closed system; instead, it can be and should be broadened to become a public-spirited self (19) that is deepened in self-transformation through genuine communication with others. From the Confucian point of view, family, community, country and even world are spheres of selfhood where one engages in promoting and transforming oneself.

In contrast, the Western liberal tradition emphasizes that persons are autonomous, rational, and self-conscious individuals who "[make] context-free choices in a conceptual vacuum." (20) It is a person's separateness, individuality, and distinctiveness, rather than his relatedness, mutuality, and communion with others, that are valued. As Hansen (21) notes, "Western theorists have understood the world as made up of particulars. Chinese metaphysical theory analyzes objects as parts carved out of a large, more basic whole."

Confucianism and Patient Care

While Western modern medical practice endorses patient autonomy by relying on a person's moral faculties of rationality and self-consciousness, Confucianism perceives autonomy as contextually and conceptually dependent: the ideal person commits himself to altruism autonomously, as his self-realization consists in moral self-cultivation and giving peace and security to people. Therefore, when a doctor approaches his patient from a Confucian perspective, he not only sees a person whose autonomy and dignity are to be respected, but also a relational being with a family, a community and a social-historical context--a small self, encompassed by one or many greater selves. In a traditional Confucian context, the family, more than the individual, is considered the basic unit, and doctors tend to seek the opinions and decisions made or agreed by the family as a whole. This is because of the emphasis on family values (wu-lun), the role family takes in caring for the sick, and the interconnectedness and interdependence between family members. Families are always taken seriously.

In this family-oriented practice, it is not uncommon, however, for there to be a strong, key decision-maker in a family whose decisions may suppress the wishes of the patient. In such circumstances, the patient must be protected from potential familial manipulation or coercion. Doctors should account for patient autonomy in medical/ethical decision making, as stressed in the West, while also respecting the family.

It must not be forgotten, however, that the patient is always a person-in-relation. The value of moral personhood and human dignity lies not in the natural criteria of rationality and self-consciousness one is born with, but in fulfilling the various roles and responsibilities one takes, creating and maintaining the harmonious relationships with people and nature, contributing to the flourishing of human society, and finally, being at one with dao.

Acknowledgment

This paper is based on the author's earlier works: Tsai, D.F.C., How Should Doctors Approach Patients--A Confucian Reflection on Personhood, J Med Ethics 2001; 27: 1: 44-50 and Tsai, D.F.C., Ancient Chinese Medical Ethics and the Four Principles of Biomedical Ethics, J Med Ethics 1999; 25: 4: 315-321.

References

1. Lin KM. Traditional Chinese Medical Beliefs and Their Relevance for Mental Illness and Psychiatry. In: Kleinman A, Lin TY, eds. Normal and Abnormal Behavior in Chinese Culture. Dordrecht, Holland, D Reidel Publishing Company, 1980, p 95.

2. Tsai DF. Ancient Chinese medical ethics and the four principles of biomedical ethics. J Med Ethics 1999;25:315-321.

3. Legge J. The Great Learning. In: The Chinese Classics. Vol 1. Taipei, SMC Publishing Inc, 1991, p 359.

4. Legge J. The I Ching. New York, Dover Publications, 1963, p 355.

5. Lin YT. From Pagan to Christian. New York, The World Publishing Company, 1959, p 71.

6. Schwartz BI. The World of Thought in Ancient China. Cambridge, MA, The Belknap Press of Harvard University Press, 1985, p 67.

7. Chan WT. A Source Book in Chinese Philosophy. Princeton, NJ, Princeton University Press, 1969, p 104.

8. Schwartz BI. The World of Thought in Ancient China. Cambridge, MA, The Belknap Press of Harvard University Press, 1985, p 68.

9. Lin YT. From Pagan to Christian. New York, The World Publishing Company, 1959, p 68.

10. Tsai DF. How should doctors approach patients? A Confucian reflection on personhood. J Med Ethics 2001;27:44-50.

11. Chan WT. A Source Book in Chinese Philosophy. Princeton, NJ, Princeton University Press, 1969, p 43, 45.

12. Chan WT. A Source Book in Chinese Philosophy. Princeton, NJ, Princeton University Press, 1969, p 105.

13. See reference 7:20. The key concepts of Confucianism. see Tsai, DF. The bioethical principles and Confucius' moral philosophy. J Med Ethics 2005;31:159-163.

14. Fingarette H. Confucius: The Secular as Sacred. New York/Hagerstown/San Francisco/London, Harper & Row, 1972, p 34.

15. Liang SM. Chung-kuo wen hua yao-i. (The essential features of Chinese culture). (Hong Kong: Chi-cheng T'u-Shu Kung-Hsu, 1974), Cited in Tao J, 'The Moral Foundation of Welfare in Chinese Society: Between Virtues and Rights. In: Becker GK, ed. Ethics in Business and Society: Chinese and Western Perspectives. Hong Kong, Springer, 1997, pp 9-24.

16. Tu WM. Selfhood and otherness. In: Confucian Thought: Selfhood as Creative Transformation. New York, State University of New York Press, 1985, p 113.

17. Tu WM. A Confucian Perspective on Learning to be Human. In: Confucian Thought: Selfhood as Creative Transformation. New York, State University of New York Press, 1985, p 55.

18. Tao J. The Moral Foundation of Welfare in Chinese Society: Between Virtues and Rights, op. cit., p 16.

19. Tu WM. A Confucian Perspective on Learning to be Human. op. cit., p 58.

20. Lee KS. Some Confucianist reflections on the concept of autonomous individual. Journal of Chinese Philosophy 1994;21:49-59.

21. Hansen C. Chinese philosophy and human rights: an application of comparative ethics. In: Becker GK, ed. Ethics in Business and Society: Chinese and Western Perspectives. Hong Kong, Springer, 1997, p 108.

To put the world right in order, we must first put the nation in order;
to put the nation in order, we must first put the family in order; to
put the family in order, we must first cultivate our personal life; we
must first set our hearts right.
--Confucius

Daniel Fu-Chang Tsai, MD, PHD

From the Departments of Social Medicine and Family Medicine, National Taiwan University College of Medicine, and the Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan.

Reprint requests to Daniel Fu-Chang Tsai, MD, PhD, Department of Social Medicine, National Taiwan University College of Medicine, No. 1, Sect. 1, Jen-Ai Road, Taipei, 100, Taiwan. Email: [e-mail]