III. CHINA. B. CONTEMPORARY CHINA

Republican Period (1912–1949)

In January 1912, after decades of social upheaval and a failed struggle to achieve a constitutional government, the Qing dynasty, which had ruled China since 1644, collapsed and the Republic of China was inaugurated, with Sun Yat-sen (1866–1925) as its first president. Although the Republic was enmeshed in constant political and social turmoil, a strong movement of visionary intellectuals pressed for the modernization of Chinese life in all its aspects. While many reformers called for the wholesale abolition of Chinese culture and customs, others sought to blend Western political forms and scientific technology with what they saw as "the essence of Chinese culture." The Chinese attitude toward medicine during most of the twentieth century has been formed by these conflicts.

Western medicine had achieved recognition, principally among the elite but to some extent in the general population, during the latter decades of the nineteenth and first years of the twentieth centuries, largely due to the influence of Christian missionary physicians and nurses, and the hospitals they maintained. The effectiveness of the Northern Manchuria Plague Prevention Service, organized along Western lines to combat the 1910–1911 epidemic of pneumonic plague in Manchuria, heightened the prestige of Western medicine, particularly in its preventive and public-health aspects. (It was on the occasion of this epidemic that two practices abhorrent to Confucian morality, cremation and autopsy, were permitted by imperial edict.) This service was the first, and the prototype, public-health service in China (Wu). Peking Union Medical College, founded in 1915 with support from the Rockefeller Foundation, became the center of medical science and education in the Western mode. Although only a tiny segment of China's doctors practiced Western medicine, they attained positions of influence in government, education, and circles of intellectual reform. In 1914, Minister of Education Wang Daxie told a delegation of traditional physicians, "I have decided to abolish Chinese medicine" (Croizier, p. 69). In the next few decades, eighty-nine Western-style medical schools were established, and thousands of Western-trained students graduated. Although this development was frequently interrupted by wars and civil unrest, the values of modern medicine gradually took root in the Chinese soil, where they grew in uneasy association with traditional values.

The abolition of traditional medicine, however, much desired by reformers and government, was not a simple matter. Three times the Republican central government attempted to abandon traditional medicine and prohibit its practice, but each time it met with strong resistance. In 1913, the central government promulgated regulations that excluded the teaching of traditional medicine from the curriculum. In reaction, some intellectuals insisted that traditional medicine could be made more scientific and even integrated with Western medicine. They also noted that traditional doctors were likely to be the only sources of care for most people for many years to come. In 1929 Yu Yan, a physician and an official of the Ministry of Health, outlined administrative measures to curb and eventually abolish the practice of traditional medicine: traditional doctors were to be reeducated and were not allowed to organize schools or to advertise. Traditional doctors responded by organizing the first national association, the Institute for National Medicine (1931), with the goal of protecting and promoting traditional medicine. Even this group, however, affirmed that traditional medicine must be made more scientific, advocating research on the pharmacological basis of the thousands of drugs used in Chinese medicine.

Nevertheless, during the 1930s almost all Western-trained physicians refused to compromise and adamantly rejected traditional medicine. Westernizing authors, physicians and nonphysicians alike, argued that traditional medicine was unscientific, as different from Western medicine as astrology from astronomy, geomancy from geometry, alchemy from chemistry. Efforts to make traditional medicine more scientific or to ally the philosophical views of traditional medicine to the scientific principles of modern medicine were repudiated as nothing more than another example of the reactionary conservativism that had harnessed Chinese life for centuries. Such proposals were called "ignorant, nonsensical, blind, babbling." In the harsh words of one prominent physician, "Why should modern medicine accept this marriage proposal from such a lazy, stupid wife with bound feet wrapped in yards of smelly bandages?" (Croizier, p. 107). In 1933, the president of the Executive Department of the central government, Wang Jingwei, declared any discussion of yin yang or the five elements without anatomical dissection scientifically untenable, and the therapeutic efficacy of unanalyzed drugs doubtful. With his support, licensing authority over all physicians, Western or traditional, was located in the modernized Ministry of Health, thus holding traditional practitioners to standards they could hardly meet. Even so, attempts to abolish the practice of traditional medicine failed in the end. In 1949, 65 percent of all physicians practiced traditional medicine. The uneasy relationship between Western and traditional medicine would continue into the era of the People's Republic.

MEDICAL ETHICS. Ethics of Medical Practice (1933), by the Western-trained physician Song Guo-Bin (1893–1956), might be called the first modern book on Chinese medical ethics. The author sought to integrate Western medical ethics with traditional ethics drawn from Confucianism. Ethics is the tao—path or way and, by extension, principle or reality—of practicing medicine, and is constituted by the Confucian concepts of humaneness and righteousness. Song defined humaneness as the Western concept of fraternity, and righteousness as what is appropriately done in compliance with humaneness. Physicians should have a spirit of love for people and a zeal to do good. The principle of humaneness requires physicians to treat poor patients at no charge when necessary; the principle of righteousness requires physicians to be competent, not to do harm, not to take advantage of the patient's vulnerability for their own benefit, not to experiment uselessly, and not to practice favoritism. On the moral character of physicians, Song followed his predecessors, emphasizing the right ordering of one's thoughts and feelings and the right ordering of one's world: the physician who is not ordered in body and spirit can hardly order the body and spirit of his patient. The physician should have the virtues of diligence, devotion, warmheartedness, and dignity. The responsibility of the physician to the patient is to treat disease, promote health, and relieve suffering. Song was the first Chinese medical ethicist to argue systematically for the obligation of confidentiality, although he recognized that this obligation is not unconditional. The patient's consent to disclosure, possible harm to others, or the legitimate needs of criminal justice release the physician from confidentiality. Among colleagues, physicians should respect self and others, and should maintain a friendly feeling and a modest attitude. The obligation of the physician to the state and society is prevention of disease and death, applying remedial measures, research on the cause of death, and the support of public charities. Song rejected contraception and abortion as immoral. Although Song's volume was known principally within the academic world, it was acknowledged as the standard statement of ethics for modern Chinese medicine. In contrast to Song's ethical idealism, the life of the woman physician Yang Chongrui (1891–1956) represents ethics in practice. After graduating from Peking Union Medical College in 1917, she went to the countryside as one of the first Chinese physicians to bring modern medicine to the peasants, in accord with her personal maxim, "Sacrifice in order to benefit the people." She established the first school of midwifery in China and, at the end of her life, was chief of the Bureau of Maternal and Child Health. She is one of the heroines of Chinese medicine and is often cited as the ideal physician.

People's Republic Period (1949–)

On October 1, 1949, the People's Republic of China came into being, a "people's democratic dictatorship" based on Marxist principles as interpreted for China by Mao Zedong. This event marked a radical break with Chinese tradition, which, based on Confucianism, had long been in decline and was considered by the new rulers to be incompatible with progress in a revolutionary society. Medicine and healthcare were to be thoroughly modernized, first on the Soviet model and later in harmony with indigenous practices. Medical ethics was to be reformulated to serve politico-ideological work performed by healthcare providers.

The availability of healthcare to the whole Chinese population was a major goal of the People's Republic, and remarkable successes were achieved, given the resources available. From the beginning, Chairman Mao took a personal interest in policies that would improve personal and public health. Statistics for life expectancy for the population as a whole and for newborns in particular were greatly improved over those of other Third World countries, and approached the statistics of developed countries. Many endemic infectious diseases, such as cholera, smallpox, and plague, as well as many nutritional diseases, were brought under control.

HEALTHCARE IN RURAL AREAS. The first national conference on healthcare was held in August 1950. Policies that would govern healthcare were announced: they were designed to respond to the needs of workers, peasants, and soldiers; to emphasize prevention; to effect cooperation between Western and traditional medicine. Soon thereafter, the policy of mass movements was added, that is, highly organized and rapid campaigns to eradicate filth and pests and to instill habits of good health and exercise. For the first time in Chinese history, affordable and competent healthcare became available to millions of laboring people and peasants.

In June 1964, Mao Zedong issued "Instruction on Putting Stress on the Rural Areas in Health Care," in which he criticized the existing healthcare system for its elitist and urban orientation. Urban practitioners, even scientific researchers, were sent to the countryside to practice and to train the public-health workers known popularly as "bare-foot doctors." The implementation of this instruction did much to promote healthcare in the rural areas; nevertheless, at the end of the twentieth century, much remains to be done and, indeed, some deterioration has occurred. At the same time, these policies were detrimental to medical education and to scientific advances in medicine and healthcare.

TRADITIONAL AND MODERN MEDICINE. In the early years of the People's Republic, Marxist thought clearly favored modern scientific medicine and labeled traditional medicine as reactionary. Western medicine, however, was viewed as capitalist and imperialist. A realistic assessment of the need for healthcare made it clear that all available resources, including traditional medicine, had to be engaged in the vast work of bringing care to the masses. Mao Zedong issued "An Instruction on the Work of Traditional Chinese Medicine"(1954) ordering the integration of traditional and Western medicine into a unified new medicine. In research, education, and care, efforts were made to bring these two forms of medicine together. In united clinics, both sorts of practice were encouraged, Western-trained physicians were required to study traditional techniques, and many large hospitals had sections for Western and for traditional treatment. A document of 1958 stated, "The objective is … a new type of doctor, versed in both Chinese and Western medicines, and one who has acquired communist consciousness under the leadership of the Party committees" (Croizier, p. 185). The ancient practice of acupuncture, for example, was applied to surgical anaesthesia. Reports of this experiment stimulated great interest in acupuncture throughout the world (Risse).

Official policy now favors the coexistence and competition between traditional Chinese medicine and modern or Western medicine, and the integration of these two into a new medicine (Qiu, 1982). Now the debate focuses on whether traditional medicine should be taught in its pure form, which would make it difficult to attract young people, or whether it should be modernized, leaving an uncertainty about what it would then offer. By 1987, the number of traditional physicians had declined to 279,000, while the number of modern physicians had risen to 1,132,000, 80 percent of all physicians. A 1986 survey showed that only 7 percent of respondents depended exclusively on traditional physicians.

HUMAN EXPERIMENTATION. Traditional medicine had no place for human experimentation in the modern sense; research came to China with Western medicine. In the 1950s, the government revealed that during the 1930s and 1940s, some foreign and Chinese physicians at Peking Union Medical College had used poor patients as experimental subjects without their informed consent. One such experiment, done by the American physician Richard Lyman in 1936, involved filming drug-induced seizures of healthy rickshaw drivers, who had been paid the equivalent of two U.S. dollars. This film was shown publicly with sensational effect during the "Ideological Transformation" of 1951–1952 and again during the Cultural Revolution. Since that revelation, many health officials and members of the public have been hostile to human experimentation. As a result, some insufficiently developed or inefficacious therapies became widely available without adequate human testing. In the 1950s, for example, during the movement known as "Learning from the Soviet Union," Vladimir Filatov's tissue therapy, in which human or animal tissues were inserted under the skin as a "biogen" for the cure of a great variety of diseases, was widely used with some fatal results. At the same time, some medical researchers used themselves as subjects for herbal medicines or new drugs and died of poisoning. After 1980, the method of clinical pharmacological trials was introduced into China, together with the principle of informed consent. Institutional review boards to provide oversight began to be set up at the request of foreign groups sponsoring research in China, although as of 1993 there is no universal governmental regulation of research.

MEDICAL ETHICS. During the early years of the People's Republic, Mao Zedong's writings were required reading for every Chinese. In the field of healthcare all medical personnel were required to read his essays "In Memory of Dr. Norman Bethune" and "Serve the People," in which Chairman Mao urged the people to cultivate their moral character in terms of the values of life and death. When one died for the people, he argued, it was a worthy death, weightier than Tai Mountain; otherwise, it was lighter than a feather of the wild goose, as Chinese ancient historian Sima Qian put it. Mao held up as an exemplar for healthcare workers the Canadian physician Norman Bethune (1888–1939), who dedicated himself to the care of Chinese soldiers and civilians during Japan's war against China (1937–1945), praising him as a virtuous person, selflessly committed to those in need, conscientious in his work, warmhearted toward all people, and continually improving his skills. The essay on Bethune was viewed as an incomparable formulation of medical ethics during the Maoist era. Contemporary Chinese bioethics can be dated from 1979, when a conference on the philosophy of medicine, sponsored by the Chinese Society for Dialectics of Nature and the China Association of Science and Technology, was held in Guangzhou. Philosophers, physicians, and health administrators who attended this conference focused on two issues in medical ethics: the concept of death and the justifiability of euthanasia, and the delivery of healthcare without discrimination. The latter problem arose because the Cultural Revolution's emphasis on serving workers, peasants, and soldiers led to discrimination in healthcare services against persons labeled capitalists and bourgeois reactionaries, and to deaths of well-known persons as the result of negligence (Cai).

Until the 1980s, the discussion of medical ethics was confined to academic circles, specialized journals, and conferences on philosophy of medicine. Two journals, Medicine and Philosophy and Chinese Journal of Medical Ethics, appeared in the early years of the decade. In 1986 and 1987, however, two legal cases, one on active euthanasia and the other on artificial insemination by donor (AID), drew the attention of lawyers, journalists, policymakers, legislators, and the general public. The first two National Conferences on Philosophy of Medicine and Medical Ethics, devoted to social, ethical, and legal issues in euthanasia and in reproductive technology, were held in July and November 1988. The Chinese Society for Medical Ethics was established in 1988 and affiliated with the Chinese Medical Association. During the decade, most medical universities and colleges, as well as nursing schools, instituted required or elective courses on medical ethics. The curriculum includes study of the moral tradition, medicine in society, the patient-physician relationship, euthanasia, genetics, experimentation, reproduction, and health policy. Dozens of books on medical ethics were published, including Zhi-Zeng Du's An Outline of Medical Ethics (1985) and Ren-Zong Qiu's Bioethics (1987). Teachers of medical ethics, drawn from philosophy and medicine faculties, were trained in doctoral and master's programs and in special workshops.

DEATH AND EUTHANASIA. During the Cultural Revolution, the concept of brain death was criticized as "bourgeois, capitalist and reactionary," created by "Western doctors … to unscrupulously open up a source for organ transplantation" (Jiang et al., p. 225). In fact, the problem of brain death arose not so much because or organ transplantation, which is not widespread in China, but because respiratory support was increasingly being employed for terminally ill persons. This was considered both futile for the individual and wasteful of health resources. At the 1988 conference on euthanasia, all participants, including physicians, ethicists, and lawyers, endorsed the concept of brain death, following guidelines widely accepted in Western countries, such as the Harvard criteria (Qiu, 1982). As of 1993, however, no administrative or legislative rules legalize the definition of death by brain criteria. As modern techniques for life support, such as ventilation, dialysis, and artificial nutrition, have become more common, particularly in urban hospitals, the problem of their appropriate ethical use has been noted. Academic discussion of euthanasia has centered on how it might be identified as a special modality of death differentiated from natural death, accidental death, suicide, murder, and manslaughter. Ancient Chinese physicians were aware of the limits of medicine and asserted that when disease attacks the vital organs, it is beyond cure. Passive euthanasia for the terminally ill, long a part of traditional Chinese medicine, has been extended without qualm to the irreversibly comatose, seriously defective newborns, and very-low-birth-weight infants. At the 1988 conference, ethicists argued for the justifiability of euthanasia on the basis of the principles of beneficence, respect for autonomy, and justice. In the resolution passed at the conference, participants endorsed the right of terminally ill persons to choose the way of dying and encouraged the use of living wills. These principles and practices, while borrowed from U.S. bioethics, are compatible with the Confucian concept of humaneness. Other deeply embedded Chinese attitudes influence thought on this subject. For example, euthanasia for the defective newborn is rendered more acceptable in view of Buddhist beliefs that such an infant must have failed in virtue in a previous life, while Confucian filial piety often causes reluctance to allow one's parents and the elderly to die (Qiu, 1980).

Active euthanasia, however, remains a subject of debate. In 1986, in Hanzhong, Shaanxi Province, two children of a comatose woman suffering from liver cirrhosis asked physicians to end her life by an overdose of morphine, without informing their siblings. The legal case brought against them evoked widespread media discussion. After their conviction on murder charges, they appealed to the Supreme Court, which in 1991 ruled that the defendants were not guilty since the harm to the decedent was minor in view of her inevitable death. Several surveys in 1986 and 1988 showed that the majority of respondents accept passive euthanasia, and even active euthanasia in certain circumstances.

REPRODUCTIVE TECHNOLOGY. Under the influence of the Confucian view of the importance of having a male successor to carry on the ancestors' lineage, infertile couples experience heavy psychological and moral pressure. In a traditional family, the woman is often blamed for the infertility of the couple and stigmatized or abused. Eagerness for offspring is stimulating the development of reproductive technology that replaces the traditional customs of "wife borrowing" and, among the wealthy, concubinage. At the 1988 conference on social, ethical, and legal issues in reproductive technology, artificial insemination by husband (AIH) and by donor (AID) were asserted to be widely practiced among the population. Sperm banks existed in eleven provinces, most of them without procedures to address ethical and legal issues. Except for a few centers in large cities, AID is undertaken without policies relating to the selection of donors and recipients, and the legal status of the child remains unresolved. The clash of traditional values and modern society was manifested in the first legal case involving reproductive technology, in which a Shanghai family refused to accept a baby boy conceived by donor sperm. In some clinics, prenatal sex selection has been practiced. The participants in the 1988 conference argued against it on the grounds that it could worsen the sex imbalance and cause negative social consequences. In the following year, the Ministry of Health prohibited the practice. In vitro fertilization (IVF) is limited to a few centers.

FAMILY PLANNING. In the early years of the People's Republic, China's enormous population and its prospect for continuous growth were recognized as a serious threat to all the social and economic gains expected from the modernization. During the 1950s, limitations on childbirth were encouraged by mass propaganda and contraceptive education. In 1980 the government announced an official policy of "one couple, one child" (the census of 1982 showed China's population had surpassed 1 billion people). This policy has caused thorny ethical problems. Although there is widespread agreement that control of population growth and limitation of reproductive freedom are ethically justifiable in view of China's vast and growing population, argument continues over whether "one couple, one child" is the best policy and over the means employed to implement it. Not only does it conflict with the traditional value that associates more children with better fortune; it also imposes significant hardships on families in rural areas, where labor needs and the care of elderly parents require several children. A 1979 survey by the Chinese Society of Sociology found that a majority of peasants in the villages near cities want two or more children, whereas the majority of respondents in cities are satisfied with one child. The one-child policy is implemented by intensive contraceptive education, by economic incentives and penalties, by sterilization (sometimes compulsory), and by abortion (sometimes coerced). Although population-control programs are officially designed as programs of incentives, education, and persuasion, the line between persuasion and coercion is not always clear, and the efforts of zealous officials in some places have clearly crossed the line. Again, the policy is most burdensome on dwellers in rural areas, where contraceptive services are often inadequate and local officials, under pressure from above, may employ abusive means. In recent years, reports of compulsory sterilization and coerced abortion have convinced certain international agencies and foreign governments to withhold financial support for population-control efforts in China.

Traditionally abortion has not been seen as a serious ethical issue in China. Most Chinese would agree with the ancient sage, Xun Kuang (286–238 b.c.e.), who argued that human life begins at birth; abortion (and contraception) were rarely discussed in pretwentieth-century medical literature, even in treatises on gynecology. Today, however, repeated and late abortions do arouse concern among healthcare workers and ethicists. Unmarried women who become pregnant often seek a late abortion. Late abortion puts physicians in a dilemma, since it involves a conflict between obligation to the health of the patient, due to the dangers of late abortion, and obligation to the society to limit births. Finally, the socially imposed limits on reproduction and the desire for male offspring have encouraged some, especially in rural areas, to revive the ancient practice of female infanticide. This practice, long judged immoral by many commentators, such as the great philosopher Han Fei (third century b.c.e.), has always been abetted by the widespread and deep poverty of the peasants, for whom a girl child was a burden rather than a benefit. Condemned as criminal by the Law Protecting Women's Rights passed by the National People's Congress in 1992, this practice remains difficult to detect and to prosecute.

REFORM OF THE HEALTHCARE SYSTEM. Since the founding of the People's Republic in 1949, the healthcare system of China has consisted of four main components: workers' healthcare in state-owned factories or institutions; public medical service; free preventive immunization; and rural cooperative medical service. In all but the free preventive service, the costs of care are funded by the government, by employer/cooperative contributions, and by a small registration fee (typically less than the equivalent of ten cents per visit, although the fee can be graduated up to about one dollar if the patient wishes to see a professor in an academic hospital). The self- or privately employed must pay the full cost of their care. These programs have extended healthcare far more widely than ever before in China's history and have significantly improved the health of the population. Throughout most of China, patients have access to well-organized health services, provided by many levels of professionals at little cost.

Despite such progress, however, programs have faced major problems: the demand for treatment always exceeds the supply; ordinary people often receive less adequate care than officials; and almost all hospitals suffer large deficits, making renovation and replacement of equipment impossible. Since the implementation of a 1980 policy to dismantle the cooperative farms, the rural medical services have deteriorated and, in some poor rural areas, health care is not accessible to villagers. The government's most recent efforts to reform the healthcare system involve implementing the contract system that has proven successful in agriculture. In this way, hospitals can supplement their government budget by increasing fees for registration, tests, and drugs, after approval from the local Bureau for Prices. A portion of these increases will be paid by the patient and the remainder by the factories and institutions for which they work. Since 1988, economists, ethicists, health administrators, and officials of the Ministry of Health have argued over whether it is ethically justifiable to consider healthcare a market commodity.

PROFESSIONAL ETHICS CODE. In December 1988, the Ministry of Health promulgated an ethics code for medical personnel that consists of seven articles: (1) rescue the dying and heal the injured, carry out socialist humanitarianism, always keep the patient's interest in mind, treat disease and relieve suffering by every possible means; (2) respect the patient's person and rights, treat patients as equals without discrimination on the basis of nationality, sex, position, social status, and financial situation; (3) serve patients conscientiously and politely, deport oneself in a dignified manner, speak to patients in a refined manner, be amiable, care for patients with compassion, concern, and solicitude;(4) be honest in performing one's duties, conscientiously observe discipline and law, do not serve selfish interests with medicine; (5) maintain confidentiality for patients, saying nothing that would harm the patient or reveal the patient's secrets; (6) deal properly with the relationship between colleagues and coworkers, learning from each other and holding each other in respect; (7) be rigorous and dependable in work, vigorous in spirit and eager to make progress, endeavor to improve professional proficiency, continuously renew knowledge, and increase technical competence.

This is the first code of ethics promulgated in the People's Republic of China, although the Chinese Medical Association had published a very brief seven-article "Doctor's Creed" in 1937 (Wang). While the new code is quite similar to medical codes around the world, it should be noted that "respect for the patient's person and rights" does not directly translate into the Western concepts of autonomy and informed consent. While it is now much more common to inform patients fully and to allow them to choose the course of therapy, older paternalistic practices, such as refraining from telling patients their diagnosis and depending on families and even work units for decisions about a patient's care, still prevail. In China, "informed consent with the aid of family and community" might more accurately express the ethical standard.

COMPULSORY STERILIZATION OF THE MENTALLY RETARDED. A regulation for compulsory sterilization of the severely mentally retarded, promulgated in Gansu Province in 1988, specified that mentally retarded persons are to be sterilized when (1) retardation is caused by familial genetic factors, inbreeding, or other congenital factors; (2) the IQ is below 49; and (3) there is behavioral disability in language, memory, orientation, and thinking. Persons who meet these criteria are permitted to marry only after they have been sterilized. Women who meet the criteria and are pregnant must undergo abortion and be sterilized (Lei et al.). Other provinces, following Gansu's lead, drafted similar regulations on compulsory sterilization, while others were more cautious, incorporating sterilization into their comprehensive regulations on family planning. Proponents of such regulation argue that the proportion of mentally retarded persons in the population is too high, that the burden to support them is too heavy, and that the heavy burden has seriously impeded social development and will influence future generations.

At a 1992 national workshop on ethical and legal issues in limiting procreation, participants pointed out that genetic factors play only a minor role in the epidemiology of mental retardation and that data on the incidence, prevalence, and etiology of the mentally retarded population are of variable reliability and subject to widely differing interpretations. Conference participants argued that if the goal is to reduce the mentally retarded population, only those whose mental retardation is known to be caused by genetic factors should be selected for sterilization—a policy requiring an adequate number of medical geneticists to perform genetic tests and identify the causal factors of mental retardation. The effort to reduce the incidence of mental retardation should focus on improving perinatal care and maternal and child care, developing prenatal diagnosis and genetic counseling, preventing inbreeding, and implementing programs of community development. When sterilization is recommended, it should be in the best interest of the retarded person, as a contraceptive measure that reduces personal misfortune; proxy consent should be obtained. Also, it was argued that the relatively high proportion of mentally retarded persons is not a cause of economic underdevelopment, but an effect of it. From the legal perspective, compulsory sterilization infringes upon some civil rights laid down in the Constitution and other Chinese laws, such as the right to inviolability of the person and the right to guardianship for the incompetent. The considerations raised by the 1992 workshop were delivered to the government and apparently have impeded the expansion of compulsory laws. However, existing laws have not been repealed or revised, and there is no strong public protest against them.

CONTROLLING THE SPREAD OF SEXUALLY TRANSMITTED DISEASES. As a result of a major health campaign in the early years of the People's Republic, the incidence of sexually transmitted diseases in the Chinese population was drastically reduced through a combination of medical, educational, and social policies (sometimes quite harsh, particularly against prostitutes). After three decades of dormancy, sexually transmitted diseases (STD) began to rise in the 1980s: from 1980 to 1992, some 700,000 cases of STD were reported (the actual number is probably much higher), including about 1,000 persons who have tested positive for infection with human immunodeficiency virus (HIV). Countermeasures have been taken in recent years to check the epidemic of STD, and several laws, ranging from management and surveillance to prohibition of drug traf-ficking and prostitution, have been enacted. However, programs for controlling STD are inhibited by several factors. One is the revival of an ancient concept in which disease is seen as punishment for misbehavior instead of being caused by a particular microorganism. Sexually transmitted disease is sometimes called "Heaven's punishment for moral deterioration." The Chinese National Expert Committee on acquired immunodeficiency syndrome (AIDS) attempts to counter this view in "An Open Letter to Medical Care Workers," asserting, "The disease is not the punishment to an individual, but a common enemy to the whole of mankind.… Every medical-care worker ought to be full of love in the heart, and help our compatriots who are threatened by AIDS with our hands and knowledge" (National Expert Committee, p. 1). The second factor is discrimination against patients and infringement upon their individual rights. HIV-positive persons have been expelled from their jobs or schools; AIDS patients have been refused admission to hospitals. Many medical workers have expressed reluctance to care for AIDS patients. A Health Department requirement that doctors fill out an STD patient card and send it to the public health office drives patients away from care, sacrificing the opportunity for education and treatment. The third factor is the lack of legitimate and effective policy to change at-risk behavior such as drug use, prostitution, and unsafe sexual behavior. In 1992, some cities set up hot lines to provide counseling and to protect patients' rights to confidentiality and privacy.

Conclusion

Since the new policy of reform and openness initiated at the end of the 1970s, China has been undergoing yet another fundamental change. Marxism faces challenges from internal pressures and from Western ideas and economics. Confucianism is still deeply engraved in the Chinese mind, but Buddhism, Taoism, Islam, and Christianity are experiencing a revival. Tension and conflict are inevitable as diverse and often incompatible values come to the fore at this historical juncture. Many fields, including medicine, face new challenges, and in this environment the field of medical ethics is flourishing as never before in China. As in many other nations, scholars have delved into problems, published articles, initiated courses, and formed organizations devoted to bioethics.

The word ethics is now translated into Chinese as lun li, two characters signifying "hierarchical human relationships" and "principle" or "pattern." Combined, these two characters designate guidelines for interpersonal relationships. In Chinese thought, ethics, or the guide for interpersonal relationships, blends with the laws that govern the universe. Thus, traditional Chinese philosophy, particularly Confucian, has a predilection for ethics, teaching how to be human within an orderly human community. In the last two centuries, Western influence in ideas and commodities has introduced an individualism not native to Chinese thought. Since the late nineteenth century, Chinese scholars have studied Western science and philosophy, with a particular interest in philosophical pragmatism. Marxist philosophy pays relatively little attention to ethics as such, since ethics is considered to be formulated by political ideology. Despite Western and Marxist influence, traditional Chinese ethics still weighs powerfully in the Chinese mind and in Chinese society.

The current interest in bioethics in China has been stimulated and influenced by American bioethics. Several leaders in Chinese bioethics are familiar with the American literature and participate in international bioethics activities. Also, since Western scientific medicine has long prevailed in China, Western ethical concerns are readily recognized, particularly as medical technologies are diffused. Thus, the principles of American bioethics—beneficence, nonmaleficence, autonomy, and justice—are frequently cited in Chinese discussions. However, these principles are not simply foreign imports: they correspond to significant Chinese values. Beneficence corresponds to the paramount Confucian virtue, ren, translated "benevolence" or "humaneness," which traditional Chinese medicine proposed as the primary virtue of the physician. It requires compassion and help for the sick, and the duty to avoid harm, as well as the obligation to care for the poor without charge (Qiu, 1988). Respect for autonomy, while not a traditional virtue in Chinese thought or medicine, which was strongly paternalistic, does correspond to the aspirations for personal freedom and social emancipation that marked the powerful current of modernization, sometimes known as the May 14th Movement, that began in the early twentieth century and continues to influence Chinese intellectuals (Spence, 1982). While not encouraged in the culture of the People's Republic, personal autonomy plays a real, if limited, part in modern thought about bioethical issues. Finally, justice in healthcare corresponds to the socialist ideal that a healthcare system accessible to all persons, regardless of social class or economic status, is best realized by a centrally controlled, nonentrepreneurial service system (Sidel and Sidel). This ideal prompted the vast extension of health services in the 1950s and inspires debates over contemporary plans to reorganize those services. Thus, while Chinese bioethics may occasionally speak in terms similar to Western bioethics, its spirit and ideas are properly Chinese: it is a blend of traditional, modern, and socialist Chinese thought, created in the unique conditions of an evolving great nation.

ren-zong qiu

albert r. jonsen (1995)

bibliography revised

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