44.full.pdf how should doctors approach patients

7/29/2019 44.Full.pdf How Should Doctors Approach Patients

1/8

doi: 10.1136/jme.27.1.44

2001 27: 44-50J Med EthicsDaniel Fu-Chang TsaiConfucian reflection on personhoodHow should doctors approach patients? A

http://jme.bmj.com/content/27/1/44.full.htmlUpdated information and services can be found at:

These include:

References

http://jme.bmj.com/content/27/1/44.full.html#related-urlsArticle cited in:

http://jme.bmj.com/content/27/1/44.full.html#ref-list-1

This article cites 5 articles, 3 of which can be accessed free at:

serviceEmail alerting

the top right corner of the online article.Receive free email alerts when new articles cite this article. Sign up in the box at

Notes

http://jme.bmj.com/cgi/reprintformTo order reprints of this article go to:

http://jme.bmj.com/subscriptions

go to:Journal of Medical EthicsTo subscribe to

group.bmj.comon November 20, 2009 - Published byjme.bmj.comDownloaded from
http://jme.bmj.com/content/27/1/44.full.htmlhttp://jme.bmj.com/content/27/1/44.full.html#related-urlshttp://jme.bmj.com/content/27/1/44.full.html#ref-list-1http://jme.bmj.com/content/27/1/44.full.html#ref-list-1http://jme.bmj.com/cgi/reprintformhttp://jme.bmj.com/subscriptionshttp://group.bmj.com/http://jme.bmj.com/http://jme.bmj.com/http://group.bmj.com/http://jme.bmj.com/http://jme.bmj.com/subscriptionshttp://jme.bmj.com/cgi/reprintformhttp://jme.bmj.com/content/27/1/44.full.html#related-urlshttp://jme.bmj.com/content/27/1/44.full.html#ref-list-1http://jme.bmj.com/content/27/1/44.full.html


2/8

How should doctors approach patients? AConfucian reflection on personhoodDaniel Fu-Chang Tsai National Taiwan University Hospital, Taipei, Taiwan, Republic of China

AbstractThe modern doctor-patient relationship displays apatient-centred, mutual-participation characteristicrather than the former active-passive orguidance-cooperation models in terms of medicaldecision making. Respecting the wishes of patients,amounting to more than mere concern for their welfare,has become the feature central to certain modern

bioethics theories. A g roup of ethical principles such asrespect for autonomy, beneficence, non-maleficence, andjustice has been proposed by bioethicists and widelyadopted by many medical societies as an ethical guideto how doctors, in their daily practice, should treat theirpatients. However, seeing patients as persons who arerational, self-conscious beings capable of valuing theirown lives, and who are consequently entitled to theliberty and rights to choose for themselves, is in generalthe backbone of Western bioethical principles.Since Confucian philosophy has long been arepresentative of the East-Asia cultural tradition andConfucian bioethics has recently been developed as atheory of applied ethics, examining Confuciuss idea ofpersons may shed some light on the currentbioethical debates. Confuciuss concept of persons,which is best interpreted via his theories of

chun-tze, (the morally ideal person) encapsulatinga two-dimensional approach, (the autonomousperson and the relational person), provides a morecomprehensive model regarding what a person is andhow he/she should be treated. This two-dimensionalapproach sees a person not only as a rational,autonomous agent but also as a relational, altruisticidentity whose self actualisation involves incessantparticipating in and promoting of the welfare of hisfellow persons. Hence this may balance the cur rentbioethical trend whereby respect for autonomy oftentriumphs.

(Journal of Medical Ethics 2001;27:4450)

Keywords: Personhood; autonomy; Confucian ethics;

physician-patient relationship; principle-oriented bioethics

Bioethical problems arise within any societywhether it be biotechnologically advanced or not.However, the more a society becomes biotechno-logically advanced, the more the number ofbioethical issues and their importance tend toincrease. The attention-grabbing bioethical issuessuch as animal or human cloning, artificialreproduction, designer children, surrogatemotherhood, xenotransplantation, and geneti-

cally modified food may have great impact on thefuture of human society, and have thereforeattracted the spotlight on the stage of bioethicsthey interest both the academics and the generalpublic. Yet the majority of bioethical problemsoccur in day-to-day medical decision making andremain within the boundaries of the relationshipsbetween health care professionals, patients andtheir families.

I. The physician-patient relationship andthe principles of medical ethicsIn 1955, Szasz and Hollender proposed three mod-els of the doctor-patient relationship, namely theactivity-passivity model, the guidance-cooperation model, and the mutual participationmodel, which simulate respectively the prototypeof parent-infant, parent-child (adolescent) andadult-adult models of communication.1 However,the consumer movement of the 60s and 70spromoted the mutual participation relationshipbetween doctors and patients, and the traditionalpaternalistic models were in general refuted bymodern bioethics. Respecting the wishes of patientsmore than merely promoting their welfare hasincreasingly become central to certain Westernbioethics theories.

On the other hand, one may consider thequestion how should doctors approach theirpatients now being answered by a principles-oriented bioethics. In other words, moral principlesare used as the ethical guidelines for medical prac-tice and research, which concomitantly defines howdoctors should treat their patients. DiVerentauthors have proposed diVerent moral principles.For example, Beauchamp and Childress putforward the principle of respect for autonomy,beneficence, non-maleficence, and justice as theprinciples of biomedical ethics.2 Downie andCalman indicated the principles of utility, justice,non-maleficence, compassion (benevolence), andself-development, governed by the principle ofrespect for the autonomous individual as the

consensus principles.3

Engelhardt suggested theprinciples of permission and beneficenceas theprinciples of bioethics.4 Veatch identified a set ofmoral principles which included utility, veracity,fidelity to promises, avoid killing, justice, andautonomy as principles of right actions.5 Macerhas argued that love should be the foundation ofbioethics, and presented his bioethical principles invarious forms of love, namely self-love (au-

Journal of Medical Ethics 2001;27:4450

www.jmedethics.com

http://group.bmj.com/http://jme.bmj.com/http://jme.bmj.com/http://group.bmj.com/http://jme.bmj.com/


3/8

tonomy), love of others (justice), loving life (do noharm), and loving good (beneficence).6 AlthoughdiVerent authors have proposed diVerent sets of

bioethical principles, these sets of principles areactually very similar.

If one concentrates on Beauchamp and Chil-dresss four-principles approach to bioethics, whichliterally can be regarded as the origin of theprinciples-oriented bioethics method, one can havea fair idea of how doctors should approach theirpatients as prescribed by modern Western bioeth-ics. First, is respect for autonomy: patients who arecompetent to make decisions should have a right to,and physicians should have the concomitant duty torespect their preferences regarding their own healthcare. Second, is non-maleficence: not causingharm, balancing benefit over harm to produce themaximal good for the patients. Third, is benefi-cence: to be concerned with and promote the wel-fare of patients. Fourth, is justice: fair, equitableand appropriate treatment in the light of what is

due or owed to patients.7

These four principles have played a large role inmodern Western bioethics and have been adaptedby many medical societies in North America astheir professional code of practice (regardless of thefact that principlism has been criticised by manymoral philosophy theorists). For example, theAmerican Counselling Association gave au-tonomy, non-maleficence, beneficence, justice andfidelity as their moral principles for the practi-tioners guide to ethical decision making in 1996. 8

The American Dental Association indicated thatpatient autonomy, non-maleficence, beneficence,justice, and veracity were their principles of eth-ics and code of professional conduct in 1998.9

Many other societies, such as the AmericanAcademy of Family Physicians,10 the American

College of Emergency Physicians,

11

and the Tri-Council Working Group of Canada,12 all estab-lished their professional codes of ethics with ref-erence to the four principles with more or lessmodification. These can be seen as representing theWestern bioethics approach to how doctors shouldapproach their patients. However, if one investi-gates the metaphysical foundation of the four prin-ciples, one can see that regarding persons asmoral agents bearing the capacity of self conscious-ness, rationality and the ability to value their ownlives, constitutes the moral justification for respect-ing a persons wishes and promoting his welfareFurthermore, since persons are generally born withsuch moral capacities and are thus similar to eachother, they deserve to be considered as equals andto be treated with fairness.

II. Why Confuciuss ethics ?Confucius is one of the most influential thinkers ofEastern philosophy and a representative of Easternculture. Among the worlds great philosophers,Confucius, together with Socrates, Gautama Bud-dha, and Jesus Christ were regarded as the fourparadigmatic individuals by Jaspers, because oftheir extended influence through two millennia and

their extraordinary importance for all philosophy.13

A brief comparison with Socrates may give us aprima facie idea of Confucius since Socrates is gen-

erally called the Western Confucius and Confu-cius, the Eastern Socrates. They were bothearnest and devoted teachers, and interested in theproblems of man; they both established ethicaltheories which were not based on religion; theyboth advocated the necessity for rulers of compe-tence and virtue; they both demonstrated sensibil-ity and the common touch, and they were bothalready famous before their death. They werediVerent in the following aspects: Confucius tookthe position of preserving and embellishing tra-ditional cultures, yet Socrates was sceptical andcritical of them; Confucius was of the style thatstrove to save the country and people, whereas Soc-rates deeply revered the love of wisdom; Confuciusemphasised personal reflection in the pursuit of areasonable social life, while Socrates emphasisedthe importance of definition and sought accuracy

of knowledge and thought.14

Confucianism has been the dominant ideology inChinese philosophy since the Han Dynasty(206BC220AD) and has directed social, political,educational, and moral thoughts in Chinesesociety.15 The author has argued that ancientChinese medical ethics was also established on thefoundation of Confucian ethics.16 Under theinfluence of certain Confucian ideology, Chinesephysicians were respected as highly as the Confu-cian politicians who were able to accomplish theiraspiration to bring peace and prosperity to people.Therefore, they were expected to be virtuous to thepoint of achieving the moral standard of an idealConfucian person, chun-tzu (the superior man).Since the concept of persons plays such afundamental role in modern Western bioethics,

examining Confuciuss idea of persons may shedsome light on current bioethical debates.

III. Persons in modern Western bioethicsThe complex and diverse conceptions of person-hood have led to deep controversies in Westernphilosophy in general and bioethics in particular.Traditional thinking presupposes all humanbeingsthe species homo sapiensare persons andthat this is an indisputable, self-evident truth.Devine described this as the species principle:human organisms, no matter their degree of matu-rity or decay, are persons, whereas non-human ani-mals, robots, or extraterrestrial life cannot bepersons.17 Since the Judaeo-Christian tradition seeshuman beings as having been created in the imageof God, and human dignity and rights flowing from

Gods creation, they also assert that all humanbeings are persons. However, these traditionalistconceptions of personhood are challenged bybioethical dilemmas. Should an embryo or fetus,without any likeness to human beings, share thesame dignity and rights as persons? Can someonewho is in a permanent vegetative state, having losthis or her consciousness and rationality forever, stillbe treated as a person?

Tsai 45

www.jmedethics.com



4/8

Philosophers and bioethicists who took a liberalpoint of view argued against the traditional positionand separated persons from human beings.

That is to say that if a human being were not atthe same time a person, he would have no humanrights. As Engelhardt suggests: Persons, nothumans, are special.18 Nevertheless, how isperson defined? In modern Western philosophy,Descartes defined a person as a thinking thing.John Locke identified a person as a thinking intel-ligent being that has reason and reflection and canconsider itself, the same thinking thing, in diVerenttimes and places, whereas human being onlymeans a corporeal existence.19 Most importantly,according to Kant, a person is a rational agentcapable of acting freely and autonomously.

In modern bioethics, Singer distinguished twomeanings of human beingsone, a member of thespecies homo sapiens, two, a being who possessescertain qualities such as self-awareness, self-control, a sense of the future, a sense of the past, the

capacity to relate to others, concern for others,communication and curiosity which was a listproposed by Fletcher as constituting the indica-tors of humanhood.20 As Singer defined it, onlyhuman beings in the second sense are persons,and thus deserving of rights and respect. He thensuggested that rat ionali ty and self-consciousness are the crucial characteristics ofpersons.

Warren also distinguished a genetic sense anda moral sense of being human and pointed outthat the feature of consciousness and the capacityto feel pain could constitute personhood.21 Tooleyindicated that a person must have the awareness ofself as a continuing entity and be capable of hav-ing an interest in his own continued existence.22

Harris argued that a person is any being capable of

valuing its own existence.

23

Engelhardt proposedthat those who have the four characteristics: selfconsciousness, rationality, freedom to choose, andbeing in possession of a sense of moral concern, arepersons in the strict sense. While human beingssuch as infants, the profoundly mentally retarded,the permanently comatose, and individuals withadvanced Alzheimers disease, who lack those char-acteristics, are merely persons in a social sense.24

Although these conceptions placed diVerentemphasis on what should be counted as the stand-ards of personhood, they all stress that rationality,self-consciousness, and autonomous moral agencyare the key features of persons. In other words,modern bioethics principles are established on thefoundation that persons are rational, self-conscious,autonomous moral agents who have liberty and theright to choose for themselves, and should therefore

be treated equally and with the utmost respect.

IV. Confuciuss concept of personsConfuciuss concept of persons is expressed in hismoral ideal of a chun-tze. Chun-tze in Confuciussethics is the man of high moral achievement whoconstantly tries to improve and cultivate himself toattain various stages of perfection. He is the

embodiment of Confuciuss moral ideal of man.Many characteristics of a chun-tze reflect thor-oughly the distinctive features of an autonomous

person.

1. CHUN-TZE AS AN AUTONOMOUS PERSON: THEVERTICAL DIMENSION OF PERSONS

The concept of chun-tze comprises various mean-ings that are commensurate with the idea ofautonomous persons. Firstly, self activation: in theBook of Change it is said: Heaven, in its motion,gives the idea of strength. Chun-tze, in accordancewith this, nerves himself to ceaseless activity. 25 Inorder to undergo this unceasing self renewal byimitating the constant running of the celestial plan-ets, chun-tze has to be a man of self activation andperseverance.

Secondly, self cultivation: Confucius said:When substance exceeds refinement, one becomesrude. When refinement exceeds substance, one

becomes urbane. It is only when ones substanceand refinement are properly blended that onebecomes a superior man.26 This indicates that asuperior man needs to cultivate himself and find abalance between unadorned human nature andmoral and social cultivation.

Thirdly, self reflection: Mencius said: If a manlove others, and no responsive attachment is shownto him, let him turn inwards and examine his ownhumaneness (jen). If he is trying to rule others, andhis government is unsuccessful, let him turninwards and examine his wisdom. If he treats otherspolitely (li), and they do not return his politeness,let him turn inwards and examine his own feeling ofrespect. When we do not, by what we do, realisewhat we desire, we must turn inwards, examineourselves in every point.27

Fourthly, self reliance: the superior man seeks inhimself, not in others28; he worries only about hisown inability, not about others failure to under-stand him.29 Neither would he blame Heaven orothers for his own failure,30 nor does he rely on oth-ers for his success; he is a man of self reliance.Mencius described chun-tze as the man whoseheart cannot be dissipated by the power of wealthand honours, who cannot be influenced by povertyor humble stations, who cannot be subdued byforce and might.31 This capacity to withstand thetrials of both adversity and prosperity, to resist thecontrolling forces of temptation, coercion andmanipulation, reveals that the person is possessedof the qualities of self reliance, self determination,and a strong moral will.

Fifthly, moral authenticity: Confucius empha-sised that the moral characters of a chun-tze must be

authentic, not merely a conformity to the socialnorm. He said: He who puts on an appearance ofstern firmness, while inwardly he is weak, is like oneof the small mean men; yea, is he not like the thiefwho breaks through, or climbs over a wall?32 Yourgood, careful [hypocritical] people of the village(hsiang yuan) are the thieves of virtue.33 A manwith clever words and an ingratiating appearance isseldom a man of humaneness.34 A man who is

46 How should doctors approach patients? A Confucian reflection on personhood

www.jmedethics.com



5/8

strong, resolute, simple, and slow to speak is near tohumaneness.35 Confucius hated hypocrites andreprehended those who spoke eloquently and

behaved ingratiatingly towards the public yet lackedthe genuine concern of humaneness and moralauthenticity inside; he called them the thieves ofvirtue.

In summary, the superior man sees himself as themaster of his own life and attributes all responsibili-ties to himself and not to someone else. He is a selfstarter and self legislator, and refuses to be control-led or coerced by others. The goal of Confuciussmoral philosophy and moral education in reality isto create an autonomous person who is self-activated, self-determined, self-reliant, and is con-stantly improving himself via moral self cultivation.

Apart from being an autonomous person,chun-tze has another prominent feature as empha-sised in Confuciuss ethics, that is, the relationalperspectives.

2. CHUN-TZE AS A RELATIONAL PERSON: THEHORIZONTAL DIMENSION OF PERSONS

The central theme of Confuciuss ethics, humane-ness (jen), which in the Chinese character meanstwo persons and is pronounced in the same way asthe Chinese word human, reflects the idea ofrelational personhood because the Chinese concep-tion of man is based on the individuals transac-tions with his fellow human beings.36 The Chineseword lun-li (ethic), which implies the reason orlogic (li) of human relationship (lun), is notquite the same as dao-der (morality) which,verbatim, indicates the way (dao) of virtue (der),whereas in English morality and ethics havequite similar meanings and are usually interchange-able. Ethics in Chinese simply directs onetowards the ideal interpersonal relationship, as theauthor defines itthe horizontal dimension ofbeing a person. In contrast, both the modernbioethical conceptions of personhood which focuson self consciousness, rationality and the autono-mous moral agent, and the Judaeo-Christian tradi-tion,which see persons as a creation in Gods imagethat reflects Gods glory, primarily refer to thevertical dimension of being a person. This is aninteresting contrast.37

According to Fingarettes understanding ofpersons in the Confucian sense, man is not anultimately autonomous being who has an inner anddecisive power, intrinsic to him, a power to selectamong real alternatives and thereby to shape a lifefor himself. Instead he is born as raw material whomust be civilized by education and thus become atruly human being.38 Liang made clear that ... in

Chinese thinking, individuals are never recognisedas separate entities; they are always regarded as partof a network, each with a specific role in relation toothers.39 He proposed that the traditional Chineseis neither individual-based nor society-based, butrelational-based.40 Tu also pointed out that self inthe classical Confucian sense is both a centre ofrelationships and a dynamic process of spiritualdevelopment41: whereas one becomes fully

human through continuous interaction with otherhuman beings and ones dignity as a persondepends as much on communal participation as on

ones own sense of self-respect.42

In other words, a Confucian person is sociallysituated, defined, and shaped in a relational contextwhere he must achieve humaneness (jen) throughinteraction with other particular individuals.43 PutdiVerently, the self develops its contours, unfoldsits characteristics, takes shape, becomes actual andindividuated through engaging and interacting in anetwork of relations with others . . . . Self-individuation is possible only through a process ofengagement with others within the context of onessocial roles and relationships.44 This concept ech-oes the original Latin term of person, (persona)meaning a theatrical mask worn by an actor in clas-sical drama. By putting on masks the actorssignified that they were acting a role, hence personcame to mean one who plays a role in life.45

In contrast, the classical liberal tradition empha-

sises that persons are autonomous, rational, andself-conscious individuals who are makingcontext-free choices in a conceptual vacuum46 andcapable of identifying and pursuing their own good.Being conceived as sovereign agents of choices,persons hence deserve equal concern and respecttheir rights and privacy are inviolable; even a collec-tive goal and the collective good are not suYcient reasonsto compromise them. In other words, it is a personsseparateness, individuality, and distinctivenessrather than his relatedness, mutuality, and com-munion with others that are valued. To sum up thisgeneral contrast between Chinese and the West,using Hansens description: Western theoristshave understood the world as made up of particu-lars. Chinese metaphysical theory analyses objectsas parts carved out of a large, more basic whole. 47

3. SELFHOODApart from stressing the relatedness rather thanseparateness of personhood, two more pointsconcerning Confucian selfhood should be brieflymentioned here. Firstly, the boundaries betweenself and others in Chinese philosophy are notalways clear: Dao, in Chinese philosophy, signifiesthe supreme metaphysical force that exists every-where in everything and dominates the exercise andfunctioning of all things in the universe. Human-kind, being bred and activated by this power, inher-its the infinite potential of dao. In other words, daois embodied in a persons selfhood as well as exist-ent in every other being. For this reason, theboundaries between the creator and the created, thecosmos and the individual, the selfness and oth-

ernessare not always clear. As Elvin said: Perhapsthis absence of alienation from the world gave theself in China slightly less sharply defined marginsthan it had in the West. For the Chinese, this lifewas neither a vale of tears, nor a testing-ground, buta home.48 The self, as the centre of relations, is notmerely a privatised self, the small self and a selfthat is a closed system. Instead, it can be andshould be broadened to become a public-spirited,

Tsai 47

www.jmedethics.com



6/8

great self and a self that is an open system,49 anddeepen in self transformation through genuinecommunication with others. Family, community,

country and the world, from the Confucian point ofview, are spheres of selfhood where one engages inpromoting them and transforming oneself.

Secondly, the Confucian self searches in unitywith dao: dao also symbolises the universal moralorder and the ideal status of moral achievement forman to define, pursue and accomplish. Metaphysi-cally, man realises his true self, the true manhoodwhen he lives in unity and harmony with dao. PutdiVerently, the universal moral order is a purposethat invites and demands the participation of man;man is likewise inspired by the dao in his ceaselesspursuit and transformation to be in unity with dao.Therefore, the self in Confuciuss ethics is notalienated from the universe, and nor is the universelifeless and soulless but, instead, lively andpurposive. The true self, in its sincere pursuit ofdao, participates and thus transforms the universe

as well. For this reason, Confucius said: It is manthat can make the dao great, not the dao that canmake man great.50 The concept of the selfsearches in unity with dao is beautifully explicatedin Chung-yung(The Doctrine of the Mean):

Only those who are absolutely sincere can fullydevelop their nature. If they can fully develop theirnature, they can fully develop the nature of others.If they can then fully develop the nature of others,they can then fully develop the nature of things. Ifthey can fully develop the nature of things, they canthen assist in the transforming and nourishingprocess of Heaven and Earth. If they can assist inthe transforming and nourishing process of Heavenand Earth, they can thus form a trinity with Heavenand Earth.51

V. ConclusionWhile examining Confuciuss conceptions of two-dimensional personhood: the vertical dimension,the autonomous, self-cultivating one, and the hori-zontal dimension, the relational, altruistic one, theauthor has reflected on how doctors shouldapproach their patients.

Persons in the Confucian sense comprise notmerely the moral faculties of rationality and selfconsciousness that one is born with, but also moralaccomplishment. This accomplishment arises in acultural-historical tradition which stresses the indi-viduals relationships with, and altruistic responsi-bility towards, others. When a person exercisesautonomy, he is not choosing in a context-free,conceptual vacuum but considers himself a person-

in-relation, with many roles to play and responsi-bilities to take, in accordance with diVerentrelationships. A person cannot become fully humanwithout fulfilling his role-specified relation-oriented responsibilities; the Confucian person-hood is to be realised through interpersonal trans-actions in human society.

Therefore when a doctor approaches his patient,he sees a person not only as a moral agent with

autonomy and dignity to be respected, namely, thepatients concerns, preferences and choices to berespected and his rights protected. He also sees the

patient as a relational being with certain family,community and social-historical contexts: a smallself encompassed by one or many greater selves. Ina Confucian context, the family, more than theindividual, is often considered as one basic unit inthe two aspects of doctor-patient relationships.Medical ethical decision making tends to respectthe opinions and decisions made or agreed to by thefamily as a whole. Given the concept of relationalpersonhood, the emphasis on family values, thelarge role and responsibility family usually take incaring for sick persons, and the interconnectednessand interdependence between family members,families must be taken seriously. After all, medicaldecisions taken by the patient often greatlyinfluence family members (especially in a tra-ditional Chinese family system), among whom themorality of intimacy cannot be replaced or over-ruled by the ethics of impartiality, universality, andindividualism of moral strangers. Moreover, whena doctor helps to maintain harmonious relation-ships among families and helps to bring agreementout of conflicts, he is in eVect seeking to maximisethe long term welfare of the patient.

Nevertheless, vices might be induced if one con-centrates merely on the relational perspectives ofpersons. For example:

emphasising filial piety (Shiaw), family values andthe common good may cause the patient to recon-cile their right of autonomous decision-makingwith the preferential choice of the families or socialvalues, willy-nilly. Putting the public interest beforeself-interest and individual rights, in addition tohighlighting the individual responsibility to the

group, may lead to collectivism. A more paternal-istic and patriarchal society came from the histori-cal tradition and social practice may naturally leadthe doctor-patient-family relationship and medicaldecision-making to be inclined towards medicalpaternalism.52

For these reasons, the autonomous perspective, thevertical dimension of persons is likely to besuppressed by the relational perspective, thehorizontal dimension of persons, resulting in thesacrificing of a patients rights and autonomy, andin the jeopardising of the cultivation of an autono-mous person.

Hence, some may argue that there is no verticaldimension at all in the Confucian personhood. Thisis incorrect. The author has explained that the aimof Confuciuss moral education is for the making of

autonomous persons. To say that the verticaldimension and the horizontal dimension of Confu-cian personhood are incompatible with each otheris also mistaken. They are two fundamentally coex-isting, mutually supportive rather than exclusive,but sometimes competing, values in Confuciussethics, which require constant balancing andreconciliation in practice. A (competent) patientsdecision making concerning his personal moral


www.jmedethics.com



7/8

values should unexceptionally be an autonomouschoice of his own. On the other hand one shouldnot forget the fact that, however such decisions are

made, the patient, the agent, is always a person-in-relation. The tension might be diYcult to resolve,but the traditional tendency of social orientationshould surely be balanced by, and reconciled with,respecting the individuals rights and autonomy. Inorder to do this it is necessary to highlight the ver-tical dimension of a chun-tze, the values of being anautonomous, self-determined, self-reliant personand the respect due to that person, to the same levelof importance as the horizontal dimension of achun-tze, the realisation of self through altruism andincessantly participating in interpersonal interac-tions, which were emphasised so much in Confu-cian society.

Therefore, Chinese health care practitionersshould be aware of how to protect their patientsfrom being manipulated or coerced by the collectiv-ist pressure (mostly from their families) and

promote their autonomy without despising theirtraditional family values. For certain Westernbioethicists, Confucian morality reminds them thatthe current ethos of individualism and regardingrespect for autonomy as trump can neverdescribe the whole picture of morality satisfactorily,nor can it give biomedical ethics a fundamentaldirection. To be a person is to be a part of a familyand community where these are the locus formorality. The ultimate concern of this Confucian,two-dimensional person lies in fulfilling his dutiesin the various roles he plays, creating and maintain-ing the harmonious relationships with people andnature, contributing to the flourishing of humansociety, and at the end of the day being at one withdao.The sense of human dignity and worth is notthe natural criteria of rationality and self conscious-

ness one is born with but a moral accomplishmentfor one to achieve.

AcknowledgementThe author would like to thank Professor JohnHarris and the colleagues participating in the Sec-ond Sino-German Symposium on Chinese MedicalEthics for their comments on the earlier drafts ofthis paper.

Daniel Fu-Chang Tsai MD, PhD (Health CareEthics) is an Attending Physician at the Department ofFamily Medicine, National Taiwan University Hospi-tal and a Lecturer at the College of Medicine, NationalTaiwan University, Taipei, Taiwan, Republic of China.

References

1 Szasz TS, Hollender MH. A contribution to the philosophy ofmedicine. Archives of Internal Medicine 1956;97:585-92.

2 Beauchamp TL, Childress JF. Principles of biomedical ethics [4thed]. New York: Oxford University Press, 1994.

3 Downie RS, Calman KC. Healthy respect. Oxford: Oxford Uni-versity Press, 1994.

4 Engelhardt HT. The foundation of bioethics. New York: OxfordUniversity Press, 1996.

5 Veatch R. Theories of bioethics. In: Global bioethics: the 4thWorld Congress of Bioethics program book. Proceedings of a con-ference presented by the International Association of Bioethicsin conjunction with the Asian Bioethics Association, 4-7 Nov

1998, Tokyo, Japan.6 Macer DRJ. Bioethics is love of life: an alternative textbook.Christchurch, NZ: Eubios Ethics Institute, 1998.

7 Gillon R. Medical ethics: four principles plus attention toscope. British Medical Journal1994;309:184-8.

8 http://www.counseling.org/resources/pracguide.htm9 http://www.ada.org/prac/code/i-intro.html

10 http://www.aafp.org/fpm/971000fm/ethics.html11 http://www.acep.org/POLICY/PO400188.htm12 The Tri-Council Working Group was comprised of the Medi-

cal Research Council of Canada, the Natural Sciences andEngineering Research Council of Canada and the SocialSciences and Humanities Research Council of Canada, 1997.

13 Jaspers K. The great philosophers. London: Rupert Hart-Davis,1962: 6.

14 Wei JT. Hsien qin chi da zhe xue jia (The seven great philosophersbefore the Qin dynasty). Taipei: BuValo Book Co, 1985:11.

15 Apart from Confucianism, Daoism and Buddhism are also veryinfluential in Chinese culture. However, Confucianism hasremained the position of cultural orthodoxy through the twomillennia.

16 Tsai DFC.Ancient Chinese medical ethics and the four princi-ples of biomedical ethics. Journal of Medical Ethics 1999;25:

315-21.17 Devine PE. The species principle and the potential principle.

In: Brody B, Engelhardt HT, eds. Bioethics: readings and cases.New Jersey,Englewood CliVs: Prentice-Hall Inc, 1987:136-41.

18 Engelhardt HT. The foundation of bioethics. New York: OxfordUniversity Press, 1986:104.

19 Locke J. An essay concerning human understanding [book II].London: Oxford University Press, 1964: ch 27.

20 Singer P. Practical ethics. Cambridge: Cambridge UniversityPress, 1979:86. See also: Fletcher J. Indicators of humanhood:a tentative profile of man. The Hastings Center Report 1972;2:5.

21 Rudman S. Concepts of person and Christian ethics. Cambridge:Cambridge University Press, 1997:46-7.

22 Tooley M. The criterion of awareness of self as a continuingentity. See reference 17:146-52.

23 Harris J. The value of life. London: Routledge, 1985: 18.24 See reference 4: 136-47.25 Legge J, trans. The I Ching. New York: Dover Publications,

1963: 267.26 Chan WT. A source book in Chinese philosophy. New Jersey: Prin-

ceton University Press, 1969:29. Translation modified by theauthor.

27 Legge J, trans. The work of Mencius, the Chinese classics [vol II].Taipei: SMC Publishing Inc, 1991: 294-5. Mencius is generallyregarded as the greatest successor to Confucius. Translationmodified by the author.

28 Legge J, trans. Confucian analects, the Chinese classics [vol I].Taipei: SMC Publishing Inc, 1991: 300.

29 See reference 28: 287.30 See reference 28: 288.31 See reference 26: 72.32 See reference 28: 324.33 See reference 28: 324. Translation modified by the author.34 See reference 26: 20.35 See reference 26: 41.36 Hsu FLK.Psychological homeostasis andjen: a conceptual tool

for advancing psychological anthropology. American Anthro-pologist1971;73:23-44. [Hsus italics]

37 Although Confucius never denied the creation of humankindby the transcendent heaven (tien), he did not refer to the moralpersonhood to be found in any particular act of the creation.On the other hand, communitarianism and feminist ethics alsocriticised liberalism for neglecting the communal and relationaldimensions of persons.

38 Fingarette H. Confuciusthe secular as sacred. New York/Hager-stown/San Francisco/London: Harper & Row, 1972: 34.

39 Liang SM. Chung-kuo wen hua yao-i [The essential features ofChinese culture)] Hong Kong: Chi-cheng Tu-Shu Kung-Hsu,1974. Cited in: Tao J. The moral foundation of welfare in Chi-nese society: between virtues and rights. In: Becker GK, ed.Ethics in business and societyChinese and Western perspectives.Hong Kong: Springer, 1997:9-24.

40 Liang SM. Chung-kuo wen hua yao-i [The essential features ofChinese culture]. See reference 39: 94. Cited in: King AYC,Bond MH. The Confucian paradigm of man: a sociologicalview. In: Tseng WS, Wu DYH, eds. Chinese culture and mentalhealth. Orlando: Academic Press Inc, 1985: 31.

Tsai 49

www.jmedethics.com



8/8

41 Tu WM. Selfhood and otherness. Confucian thought:selfhood ascreative transformation. New York: State University of New YorkPress, 1985: 113.

42 Tu WM. A Confucian perspective on learning to be human.

See reference 41: 55.43 King AYC, Bond MH. The Confucian paradigm of man: asociological view. See reference 40: Tseng WS, Wu DYH: 31.

44 Tao J. The moral foundation of welfare in Chinese society:between virtues and rights. See reference 39: 16.

45 See reference 20: 87.46 Lee KS. Some Confucianist reflections on the concept of the

autonomous individual. Journal of Chinese Philosophy 1994;21:49-59.

47 Hansen C. Chinese philosophy and human rights: anapplication of comparative ethics. In: Becker GK, ed. Ethics inbusiness and societyChinese and Western perspectives. S eereference 39: 108.

48 Elvin M. Between the earth and heaven: conception of the selfin China. In Carrithers M, Colins S, Lukes S, eds. The categoryof the person. Cambridge: Cambridge University Press, 1987:13-14.

49 See reference 42: 58.50 See reference 26: 44.51 See reference 26: 107-8.52 See reference16: 20-1.


www.jmedethics.com


44.full.pdf how should doctors approach patients

Documents