Medical Ethics, History of South and East Asia: I. General Survey

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I. GENERAL SURVEY

The entries that follow deal with the complex and varied traditions of medical ethics and practice in east, south, and southeast Asia. In many respects these three areas have always represented very different cultural and geographical entities. The Indian subcontinent derived its cultural and linguistic influences from central and western Asia, but produced in Hinduism and Jainism its own religious, cultural, and intellectual forms, shaping attitudes toward disease and the ethics of medical practice. Concepts of human life and disease evolved quite independently in east Asia, where an agrarian society grew up isolated from other Asian peoples both by steep mountains and by what were for the early Chinese equally impenetrable oceans. Chinese society developed its own characteristic political and social practices—particularly its religion focused on the present world, and orientation toward its ancestors. Early Japanese attitudes toward nature differed from the Chinese, as the conceptions of an island people dependent on the seas for a living differed from those of plains-dwelling farmers. Nonetheless, significant interaction between China and Japan from about the seventh century c.e. infused Confucian ideas into early Japanese foundations. Southeast Asia, today comprising Vietnam, Laos, Thailand, Malaysia, and Indonesia, and vividly characterized by Anthony Reid in The Lands Beneath the Winds, also evolved from independent social origins. As Reid writes: "Fundamental social and cultural traits distinguish Southeast Asia as a whole from either of its vast neighbors—China and India. Central among these are the concepts of spirit or 'soul-stuff' animating living things; the prominence of women in descent, ritual matters, marketing and agriculture; and the importance of debt as a determinant of social obligation" (Reid, 1988, p. 6).

Despite their very different cultural orientations, these societies are treated here as a group because they offered in traditional times a common contrast to Western medical practice and ethics, and have had throughout their histories a common influence from Buddhism. In more recent periods, the societies of east Asia have faced the common problem of reconciling the possibilities of Western medical technology with their own social goals. These common themes are explored here, by way of introduction to the more specialized articles that follow.

In traditional times, the societies of Asia never adopted the exclusively biological conception of disease that has become the norm in modern Western societies. In traditional Indian Ayurvedic medicine, as Desai Prakash argues, physicians classified the etiology of disease in three categories: external or invasive diseases caused by foreign bodies or possession states; internal diseases caused by disturbances of humors brought about by lapses in discretion; and a third category of disease brought about by the inexorable workings of karma. In ancient China, the metaphors were different but the origins of disease were understood to be equally complex, with health and illness deriving from the baneful or benevolent influence of departed ancestors, or the influence of demons. In Japan, the apprehension of human beings' relation to kami, (sacred world), and the southeast Asian conception of the relation of magic, religion, and health, allowed the possibility of social as well as strictly organic origins of disease.

These views of disease may reflect a general tendency in Asia to view the human order as more fully integrated with the natural and social orders than in the West. This contrasts with modern European conceptions of disease, which reflected a European, perhaps Promethean, notion that the human world could understand, analyze, and ultimately control the natural order. Asians' more complex vision of disease had important consequences for the relationship of the medical practitioner and his patient. Since disease could arise from a variety of sources, the Asian medical practitioner addressed a wider spectrum of issues in a patient's life than did his Western counterpart. Moreover, the Asian patient might be free to consult many more types of practitioners than the European counterpart. Hence varied traditions of medical practice existed side by side, with no single system of medicine having an exclusive legitimacy.

In part, this pluralism of Asian medical practice made it possible for Buddhist practitioners to spread throughout Asia, beginning in about the second century c.e. The notion of loving friendship, and its institutional expression in the establishment of charitable hospitals, dispensaries, and comfort stations on the way to famous shrines and temples, was one of the concepts Buddhist monks carried with them as they made their way across the trade routes of central Asia from India to China between the second and the seventh centuries c.e. Once in China, Buddhist monks found a social environment quite different from the one they had left, for although the Chinese intellectual world was open to Buddhist doctrines, Chinese society was not as open to monastic life with its implied rejection of family and ancestors. In China Mahayana or devotional Buddhism, which stressed the activities that the believer could perform while remaining within the realm of family and community, developed. Thus, in China, Buddhist healing practices not only were carried out within charitable institutions formally run by the Buddhist establishment but also came to merge with folk medicine and healing practices from other traditions.

By about the thirteenth century, the spread of Buddhism throughout Asia had provided a unity to traditional medical practice that had not existed previously. But this was at best a loose unity, in which Buddhist medical ideas came to coexist alongside traditional healing practices and institutions. When Western medicine came to Asia in more recent times, it experienced a similar fate. The importation of Western medicine to Asia was largely a product of colonial times; the earliest Western medical practitioners in Asia were often missionaries supported by European and American political or religious establishments. Twentieth-century Asian governments, consciously or unconsciously aware that Western medical technology could provide the same control over life and disease that Western military and social technology provided over political affairs, often vigorously pursued Western medical techniques. The Minister of Education of the government of Nationalist, or Guomindang, China declared in 1914 that he had "decided to abolish traditional Chinese medicine." Similarly, in 1874 the Meiji government in Japan decreed that all Japanese physicians had to have Western medical training.

Despite the vigorous efforts of Asian governments to promote Western medical education and practice, Western medicine has failed to supplant traditional medical practices in any of the countries under consideration, for several reasons. In part, the problem has been the absence of trained medical professionals: In China, for instance, despite the commitment of the government of the People's Republic to scientific medical practice, a realistic assessment of resources dictated that medical workers trained in traditional as well as modern Western techniques be employed. Possibly because of the paucity of trained personnel throughout Asia, Western medical practice has been and remains a largely urban and elite phenomenon. In part as well, traditional medical practices have proved their value as effective and inexpensive treatments for many of the maladies of modern life. As Pinit Ratanakul notes in the article on Southeast Asian countries, "This traditional method of healing may be especially suitable today for Southeast Asians, who, living in societies with increased urbanization and industrialization, need physical, psychological and spiritual care to enable them to cope with such change and the strains and stresses of modern life." Today, then, as in the past, different disciplines of medical treatment, each with its own ethical standards and requirements, exist side by side throughout much of Asia.

If modern Western medicine has not fully supplanted traditional medicine in Asia, the power and technology of modern medicine has in almost every country posed new ethical dilemmas. In some instances, as in the case of reproductive medicine, Western medicine has made accessible courses of action more radical than traditional medicine permitted. Abortion, though known and disapproved of in traditional Chinese and Indian medicine, has become much more common throughout Asia as population control has become an accepted political goal. Amniocentesis to determine the sex of a fetus has become a common practice in India, with female feticide often the consequence of the traditional religious imperative to produce a male heir. China's enthusiastic embrace of the Western market for blood products and the technology for obtaining them fostered the spread of AIDS in the 1990s in a population totally oblivious to the dangers of the technology and the disease.

In other areas of medicine, Western technology has fostered new and rather ominous practices in Asia. In China in the late 1980s, debate arose about the merits of sterilization of the mentally retarded and other types of genetic experimentation. Sadly, Asian practitioners of Western medicine have proved somewhat more willing to engage in experimentation on human subjects than have their Western counterparts, as well. Wartime experimentation during WW II by Japanese doctors in Manchuria has, of course, been condemned not only in the West but also in Japan. Unfortunately, such experimentation has also been carried out in contemporary Southeast Asia, though such action is increasingly condemned by Southeast Asian and Western governments. As a result of the new ethical dilemmas posed by Western medical technologies, medical ethics has become both a heated issue throughout contemporary Asia and the subject of frequent international conferences and journal articles.

r. kent guy (1995)

revised by author