Book Review: Nie Jingbao, “Medical Ethics in China”

London: Routledge, 2011; 263 + xiii pp

Guest Post by Yonghui Ma

For those who have a particular interest in cross-cultural bioethics, Nie’s book, Medical Ethics in China, is an absolute feast.  Luckily, I am one of them and it more than satisfied my appetite for the subject.  It brings us much closer to a fascinating but complex topic through a multi-disciplinary approach to address ethical issues and a trans-cultural interpretation far beyond the Chinese context.

 This book covers many key topics in bioethics (some are quite sensitive to Chinese) in the Chinese socio-cultural context – topics such as attitudes towards the foetuse, sexuality, medical truth-telling by medical professionals, informed consent, professional medical ethics, health promotion, human rights, and theories on personhood.  Nie examines these issues from a wide range of perspectives, from the traditional Chinese doctor’s to the modern feminist’s.  What distinguishes this book from other works is Nie’s perspective, which lies outside the mainstream of contemporary Chinese bioethics. They are based on his academic experiences in and outsideChinaand, more importantly, his in-depth understanding of the relationship between culture and ethics.  His own angle is rather unique as, in Robert Veatch’s words in the foreword of the book, he can “seriously claim to be at home as an insider in both Chinese and Western thought” rather than most others who are “rooted in one culture and communicate to others as outsiders.”  This not only makes Nie investigate medical ethics from a Chinese-Western comparative perspective but has helped him to avoid stereotypes and develop a theory of “trans-cultural bioethics”.  Overall, the book is a triumph as an exploration of transcultural medical ethics and sophisticated philosophical argument.

The book is divided into four parts and in the first two Nie identifies and proposes approaches to challenge some popular myths and stereotypes on Chinese medical ethics and culture, and Chinese-Western cultural differences.  For example, a most widespread and persistent myth is that Chinese culture is largely homogenous and its medical ethics is radically different from the West’s.  In particular, there is a widely accepted belief that the position is collectivist or communitarian China versus the individualistic West.  Indeed, it is all too tempting to imagine other categories of total opposition: family decision-making vs. individual autonomy; personal virtues vs. individual rights; the concept of social duty and obligation vs. the notion of individual freedom; trust vs. contract (p 38).  The list goes on and on.  However, Nie has swept away this sort of idea completely.  In the first four chapters he draws on a wide range of primary and secondary historical and sociological sources with philosophical analysis, to argue that this dichotomous mentality of “East is East and West is West” (p21) is fallacious and dangerous.  This approach, he states, “downplays internal plurality… is a denial of every culture as an open system … and generates contentious and harmful social policies” (pp 46-49).

Also in this section, the author has identified the popular mistakes such as “false opposites” and “false friends”, so that “the assumed cross-cultural differences are not as dramatic as they appear to be” and “the perceived similarities are not as real as they appear to be” (p69).  So in chapter four, he uses the example of the widely accepted debates and claims around blood circulation in light of The Yellow Emperor’s Classic of Medicine to illustrate the problem of “false friends”.  A later chapter illustrates the problem of “false opposites” by arguing against the belief that Chinese traditional and contemporary attitudes on nondisclosure of medical truth are vastly different from those in the West.  Drawing on historical evidence, especially ancient medical scholars and doctors, he reveals that medical truth-telling is actually a long-ignored indigenous Chinese tradition, much earlier than the West.  It dates back at least twenty-six centuries while in the West full medical disclosure became the standard only in the 1970s.  Some further flaws involved in the cultural difference argument related to informed consent are also discussed in the same vein in chapter seven.  It is argued that this view “obscures the real ethical issues at stake and promotes the tyranny of existing social-cultural practice” (p 116).  Furthermore, Nie asserts that even if medical disclosure and informed consent were culturally alien to China, ethical imperatives exist to reform the contemporary mainstream Chinese practice since the current practice of non-disclosure can cause serious harm to patients as well as their families.

Part three of the book discusses the theme of human rights, and in particular women’s rights.  Nie vigorously challenges the idea that the concept of human rights is a Western cultural norm, incompatible and not applicable to non-Western societies such as China.  He “highlights the international nature of human rights and the often-ignored positive elements of Chinese culture that promote and embody universal human values such as human rights” (p 16).  Nie accepts though that feminist bioethical discourses are necessary in China too.

The final part of this book shows how indigenous and traditional Chinese philosophy and medicine can contribute to the discussion of contemporary medical ethics in and outside of China.  Although this topic is nothing new, a large portion of the current literature centres on familism and its various associated concepts, such as filial piety, social duty and obligations from Confucian perspectives.  But in this book topics that Nie has dealt with are more innovative: professional medical ethics; the nature of medicine and patient-physician relationships; the issue of personhood; and a yin-yang model for reconciling the tension between individualism and commutarianism, the last of which would be of particular interest to those in the public health field.

Clearly, Nie has convincingly challenged the argument of cultural difference and defended his theory of transcultural bioethics: “to appreciate the complexities of cultural differences, to cherish the internal moral plurality that exists within every culture, to focus on bothe the differences and the similarities or commonalities among cultures, to promote an effective and deeper dialogue between different cultures, and most importantly, to acknowledge the necessity of normative judgments and uphold the primacy of morality” (p 226), as he beautifully puts it.

However, some important differences on Chinese-Western commonalities can be deeper than they appear and have been overlooked.  A serious challenge to Nie’s view on cross-cultural differences and similarities is that he sometimes equates behaviour to value in his analysis, which leads him to over-simplified conclusions.  In this case, he is actually committing the mistake of “false friends” he is trying to avoid.  One illustration is that when Nie draws on primary historical evidence to support his argument that some values, such as medical truth-telling and informed consent, are not alien but actually long-forgotten Chinese traditions.  He uses the example that ancient celebrated doctors practiced truth-telling and informed their patient before the treatment (chapters 6 and 7). But here, he confuses values and behaviours.  He takes informed consent as a value and moral guideline when he talks about West, but quickly regards it as simply practice when in the Chinese context.  By virtue of this practice he claims thatChinahas an underlying moral tradition.  This reasoning is problematic.  The behaviour of medical disclosure and informed consent by doctors may have existed centuries ago in China, but whether the value existed, or not, at the same time is another question.  It might also be possible that only the respected doctors complied with the principle of informed consent while the vast number of others did not, as the values probably had not yet existed nor been accepted by society at that time.  Alternatively, these doctors’ informing practice may have been motivated or driven by some completely different thoughts, other than the current values underpinning informed consent.  In modern society, informed consent is a product of a wider range of supporting social, economic, legal norms so the assertion that informed consent is a Chinese tradition is simplistic and groundless.

A similar mistake of confusing values and practices is not unusual in other topics in cross-cultural studies.  An analogous example is whether homosexuality has some origins in China and is another illustration of “false friend”.  It has been widely held that homosexual activities used to be common and even popular historically in China.  This claim is based on the fact that in many dynasties in Chinese history, it was common for wealthy people, usually emperors, to keep a same-sex younger partner for pleasure.  There was neither support nor criticism about it and it seemed it did no harm in maintaining traditional family ethics.  However, strictly speaking, these are homosexual activities and have nothing to do with the ‘gay rights’ movement of today: those homosexual activities which occurred inChina’s ancient past are conceptually and substantially different.  This is because the status of those involved in homosexual activities in the history of China, and in many other then societies, was not equal at all: it was mainly between masters and servants, monarchs and subjects, etc.  The notion of a ‘willing-partner’ in this relationship was dubious. Besides, the historical evidence is partial: only records about male homosexuals exist.  Therefore, to claim that the recent homosexual rights movement in the West is not alien but an indigenous Chinese value is empirically problematic and normatively misleading.

Yet my concern should not be interpreted as a negative assessment of the book as a whole.  On the contrary, Medical Ethics in China is a successful contribution to the development of cross-cultural bioethics. His clarification of the popular myth and stereotypes between East and West, and about medical tradition and medical ethics in China, clear the way to pursuing the common morality globally and therefore takes us to a new era of discussion on this crucial topic.  In sum, it is insightful and thought-provoking.  I highly recommend the book to anyone interested in cross-cultural bioethics, even to those who claim no interest in China.