Journal of medical ethics, 1995; 21: 239-246

Chinese Confucian culture and the medicalethical traditionGuo Zhaojiang The Fourth Military Medical University, Xian, Shaanxi, China

AbstractThe Confucian culture, rich in its contents and great inits significance, exerted on the thinking, culture andpolitical life of ancient China immense influences,unparalleled by any other school of thought or culture.Confucian theories on morality and ethics, with'goodness' as the core and 'rites' as the norm, served asthe 'key notes' of the traditional medical ethics ofChina. The viewpoints of Confucianism on benevolenceand material interests, on good and evil, onkindheartedness, and on character cultivation were allinherited by the medical workers and thus becameprominent in Chinese traditional medical ethics. Hence,it is clear that the medical profession and Confucianismhave long shared common goals in terms of ethics.

Influenced by the excellent Confucian thinking andculture, a rather highly-developed system of Chinesetraditional medical ethics emerged with a well-definedbasic content, and the system has been followed andamended by medical professionals of all generationsthroughout Chinese history. This system, just to mentionbriefly, contains concepts such as the need: to attachgreat importance to the value of life; to do one's best torescue the dying and to heal the wounded; to showconcern to those who sufferfrom diseases; to practisemedicine with honesty; to study medical skillspainstakingly; to oppose a careless style of work; tocomport oneself in a dignified manner; to respect localcustoms and to be polite; to treat patients, noble orhumble, equally, and to respect the academicachievements of others, etc.Of course, at the same time, Confucian culture has its

own historical and class limitations, which exertednegative influences on traditional medical ethics.Now, ifwe are to keep up with the development of

modern medicine, a serious topic must be addressed.That is how to retain the essence of our traditionalmedical ethics so as to maintain historic continuity andyet, at the same time, add on the new contents ofmedical ethics so as to incorporate modern features into

Key wordsConfucian ethical tradition; Chinese traditional medicine;modem medicine.

our system. Therefore, when trying to reform medicalpractice in China, we are faced with the urgent need toinherit and promulgate the essence of Confucian ethics -discarding its obsolete concepts - while at the same timebuilding up the new medical ethics that can meet therequirements of the outside world and the future.

As the world strides into the twenty-first century,scholars around the world are contemplating, fore-casting and portraying what the future will be like. Inthe next century, what kind of a world will we live in?How will we work? What moral values shall we needso as to co-ordinate and handle interpersonal rela-tions and man's relation to society? These questionshave provided much food for thought. One of themost heated debates centres on medicine, which is acommon cause for all mankind, and medical ethics,which concerns each and every one of us. My topicfor discussion is Chinese Confucian culture and themedical ethical tradition. I will expound on ChineseConfucian culture and its profound influences on,and the intrinsic connection with, the medicalethical tradition in China. I will also talk about theneed for re-examining the moral values and ethicalstandards as embodied in Confucianism in order tomeet the rapid developments in modern medicine.

I. Confucian culture and its profoundinfluencesIn the Spring and Autumn Period (770-476 BC),the slavery society in China was disintegrating and anew culture was being conceived which would shapefuture society. In this extraordinary period of historywas born an extraordinary cultural giant, KungChiu, respectfully addressed by later generations asKung Fu-tse or Confucius. Confucius (551-479BC) was a distinguished philosopher, thinker,educator and political ethicist in the late Spring andAutumn Period (1). Although he was of humbleorigin, he had an acquisitive mind and a contempla-tive nature even as a child. He was once a pettyofficial responsible for running a warehouse andraising cattle. Then he began to recruit disciples andto give lectures. He was the first to found a private

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240 Chinese Confucian culture and the medical ethical tradition

school in China. Though he later held various high-ranking official positions in the state of Lu, he was

mainly interested in founding schools, givinglectures and promulgating and promoting hisacademic views and political ambitions. Togetherwith his disciples he journeyed through much of thethen politically and economically developed regionsof China. The journey, which lasted fourteen years,

helped him gain a deeper understanding of the thenprevalent academic viewpoints and political beliefsof various schools as well as of social reality, throughcultural exchange and observation. A unique schoolof Confucianism, which exerted immense influenceson the thinking, culture and political life of ancientChina, was established by Confucius as he madehis profound inquiries into philosophical, ethical,political and educational problems.

Concept of 'conscience'After the death of Confucius, his disciples inheritedand developed his academic thoughts. Mencius(circa 390-305 BC), leader of one of the eight minorschools of thought developed from Confucianism,politically advocated the kingly way and opposed theway of might, and placed moral value on righteous-ness and despised profits. He was the first to formu-late the concept of 'conscience' in the history ofChinese ethics and he was regarded by later genera-

tions as the true inheritor of Confucianism. Tsun-tse(circa 313-238 BC) criticized all other contendingschools of thought and only revered Confucianism.Ethically, he concretized the concept of 'morality'and raised the possibility that 'man is born evil' as

opposed to the hypothesis of Mencius that 'man isborn good' (2).

In 213 BC, a well-known event in China's historytook place. Emperor Qin Shihuang, who was

offended by the political viewpoints of Confucianscholars, ordered the burning of classical writings ofConfucianists and the killing of over 460 Confucianscholars. The tragedy dealt a heavy blow to theschool of Confucianism and arrested its develop-ment for some time.

In the Han Dynasty (206 BC-220 AD), the impor-tance of the school of Confucianism's tendency to

support those in authority, such as monarchs, was

recognised; Confucianism was for the first timecrowned as the national orthodox culture whenEmperor Han Wudi issued the decree 'to ban all otherschools of thought and to sanctify Confucianism'.Confucian scholars in the period, as represented byDong Zhongsu, adapted Confucianism to form philo-sophical theory about rulers. This promulgated theconcept of 'the unity of heaven and man' and sup-

ported absolute monarchy (3).During the Tang Dynasty (618-907) we saw the

emergence of Taoism and Buddhism as rivals toConfucianism. Confucianism further developed inthe process of both rejecting and absorbing Taoism

and Buddhism. Han Yu et al tried to adaptConfucianism into a religious belief but failed (3)while other scholars developed the early Confucianthinking of 'valuing people and loving people'. In theinterim, Confucianism was beginning to be mergedwith natural sciences and medicine.

In the Song (960-1279) and the Ming(1368-1644) dynasties, Confucianism appeared inthe form of 'Confucian idealist philosophy' out ofthe fusion of Confucianism with Taoism andBuddhism, which later became the dominant philos-ophy of rulers in late feudal society (960-1840) inChina. These scholars were mainly concerned withthe philosophical problems of human nature and theway of heaven and propounded the extreme proposi-tion of 'letting the heavenly principles live and lettinghuman desire perish'. Feudal rule in China becamemore oppressive spiritually. These scholars alsomade great efforts to annotate classical Confucianwritings and consolidated the concept of 'nationalcharacter' and the Confucian ideal of a prosperousstate and a humanitarian world. No noticeabledevelopment in Confucianism occurred after theMing Dynasty.

Confucian culture by this time was extensive andwide-ranging, embracing the social, political, cultural,educational, ethical and moral aspects of life.

According to Confucian thinking, the ruling classshould learn the merits and virtues ofYao and Tsun,who were legendary monarchs since time immem-orial in China (22nd-21 st centuries, BC) andimitate Emperors Zhou Wenwang and ZhouWuwang (circa 11th century BC), two outstandingemperors of the Zhou Dynasty, in the way of govern-ing the state. Confucianists endorsed 'ritual' and'goodness and justice' and advocated 'ruling bymoral force' and 'ruling by ritual'. Confucius said:'If you rule the people and keep order among themby punishments ... they may avoid doing what iswrong, but they will also lose self respect. If youguide the people by moral force and keep orderamong them by ritual, they will keep their selfrespect and come to you of their own accord' (4).Mencius inherited Confucius's concept of benevo-lent government and promoted the kingly way ofruling people by goodness and opposed rulingpeople through might.

Profound implicationsConfucian culture is not just one academic school ofthought, it has profound connotations and implica-tions. What is more important is that Confuciusinaugurated philosophical study in China and it canbe said that he is the first great philosopher in China'shistory. He started academic debates of a philo-sophical nature on man's destiny versus humanefforts; on rule by benevolence versus rule by law; onthe innate goodness or evil of human nature; on theprocess of knowledge acquisition; on methods of

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Guo Zhaojiang 241

self-cultivation, and on other contentious topics.Confucianism is basically idealistic in nature, thoughamong distinguished Confucian scholars of variousdynasties one can always find some who werematerialistic.

It is believed by Confucian scholars that educa-tion, especially moral education, plays a decisive rolein ruling and keeping the state healthy, and that mencan become knowledgeable, sensible and capablethrough education. Not surprisingly, Confuciusstarted a private school with over 3,000 disciples.Some Confucian education theories about methodsof study and scholarly research remain useful to latergenerations.

Social orderIn Confucian culture, the importance of social ethicsand morality is also highly emphasized and instruc-tion in ethics and morality is integrated with politics.Thus, a special and unique unity of politics andethics has formed. It is held that political rule shouldbe supported by instruction in ethics and that eachand every principle and norm of ethical instructionshould be adapted so as to meet political needs.Therefore, Confucianism has become a school ofthought which teaches rulers how to rule and thecommon people how to abide by that rule andbehave properly - the aim being to maintain thesocial order which was based on hierarchy.The essence of Confucian culture, either from the

perspective of history or from that of reality, lies inits ethical and moral theory. Confucius formulated aunique system with 'goodness' as the nuclear coreconfirmed by 'rites' and advocated the idea of'guiding the people by moral force and keeping orderamong them by ritual'. Goodness as the highestmoral standard in Confucianism has dual meanings:an intense concentration of Confucius's 'politicalthinking', representing Confucius's hope that theruling class may 'rule by benevolence', and the highrealm of Confucius's moral cultivation, showing hishope that people may be 'benevolent'. To practise'goodness' lies in the loyal way: 'you yourself desirestanding, then help others to get standing. Youyourself want success, then help others to attainsuccess', and in the tolerant way: 'never do to otherswhat you would not like them to do to you' (the'golden rule' of western philosophy). Confuciusattached great importance to moral education andhe considered that people showed little differencefrom one another when born and that only educa-tion differentiated individual from individual.Therefore, he recommended that moral educationbe used as the foundation of ruling a state andemphasized the notion of 'rescuing people by moralpower'. Just as Professor Luo Guejie, a well-knownChinese ethicist pointed out, at the time whenancient Greek thinkers claimed openly that slaveswere only tools that could speak, Confucius in China

explicitly formulated the concept of loving people as'the most fundamental and the only moral principle'(1). This is of great significance in the developmentof human civilization.

'Ritual', a category rich in connotations inConfucian culture, includes anything from rites tomoral principles and from political systems to legalprinciples. But, in the commonest sense, 'ritual'mainly refers to the extensive system of moralprinciples corresponding to 'goodness'. The relationbetween 'goodness' and 'ritual' is that 'goodness' isthe soul of 'ritual', 'Goodness' is the moral standardto be attained by 'ritual', and 'ritual' is the expres-sion of 'goodness'. The former is subordinate to andserves the latter.The ethical and moral theory of Confucianism

stresses man's spiritual realm and holds that themoral demand is man's most pressing demand.Mencius regards morality as the biggest differencebetween men and animals and he ridiculed thosewho were well fed, well dressed and lived in splendidsurroundings but lacked moral cultivation, asshowing hardly any difference from animals (5,6).Confucianists also emphasized the methods ofmoral education. Confucius himself stressed 'self-restraint', 'introspection', 'self-respect' and 'self-blame'. Zeng-tse, the chief of another school ofthought, said, 'I inspect myself three times daily'.Mencius also upheld cultivation of one's moralcharacter. It can be seen that Confucian scholarsconsistently endorsed the enhancement of moralcharacter by self-inspection and self-restraint.

Zhang Zhai (1020-1077 AD) succinctly sum-marized the goal of Confucianism: to set rules andlaws for the state, to set morality for the people, toinherit the cultural achievements of ancient sages andto seek eternal peace under heaven. These features ofConfucianism met fully the needs of feudal rulers.Therefore, Confucianism was reverenced as thenation's only orthodox school of thought in variousdynasties from the time of Emperor Han Wudi(140-87 BC) and penetrated all walks of life inancient society. Confucianism developed a series ofdeep-rooted concepts in the thought, consciousnessand customs of people, becoming the mainstreamculture and defining people's thoughts, words andacts, and playing an important role in China'shistory, unparalleled by any other school of culture(7). It was involved in the whole process of creatingthe culture of feudal society and defined the tone andpattern of feudal China's social thoughts and culture.The impacts of Confucian culture have to be con-sidered ifone wants to know ancient China and studymodern China.

II. Chinese medical ethical tradition andits relation to medicine and ConfucianismThere are some legendary stories praising physiciansfor their morality before the time of recorded words.

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242 Chinese Confucian culture and the medical ethical tradition

One of the most notable stories is about the ancientEmperor, Shennong, who tasted a hundred kinds ofherbs and was poisoned 70 times one day. The storyshows that in ancient times our ancestors werewilling to sacrifice themselves in order to save livesand develop medicine. Records of ancient medicalethics can be dated back to the time prior to theformulation of Confucianism. In the Zhou Dynasty3,000 years ago, the skills and the moral character ofphysicians were examined annually and physicianswere treated differently, according to their examina-tion results (8). After the establishment ofConfucianism, its ethical and moral conceptsexerted profound influences on medical workers ofvarious dynasties and played a dominating role in thedevelopment of Chinese traditional medical ethics.

Craft of saintsFirst, there were some distinguished physicians whoadvocated medicine and opposed witchcraft. Forinstance, Hippocrates's contemporary, Bian Que(5th BC), a famous physician in the Warring StatesPeriod (475-221 BC), formulated guidelines forpractising medicine in which he proposed to trust inmedicine rather than witchcraft. He saw as a realisticgoal, the elimination of the harms of sorcery throughthe construction of medical ethics. Medical ethicswere also emphasized in the famous traditionalChinese medical classic The Yellow Emperor's Canonof Internal Medicine (9), in which it is pointed outthat medicine is the craft of saints, and a noble pro-fession and that medical workers should have noblemoral character. The book also enumerates fivetypes of fault and four types of error in medical treat-ment and physicians are warned against these faultsand errors. For example, physicians are required topractise medicine scientifically. It is also stressedthat 'one who believes in ghosts or gods cannot besaid to be benevolent' (8). For ancient physicians,advocating science and opposing superstition wasone of the important aspects of medical moralcharacter, which was highly appreciated by ancientphysicians and in ancient medical writings.

In the following 1,000 years from 500 BC to 500AD, serious inquiry was made into problems such asthe purpose of medicine, style of work, and moralcharacter cultivation. Many precious writings onmedical ethics were handed down. Zhang Zhongjing(circa 150-219 AD), a famous physician of the EastHan Dynasty, who was regarded as a 'medical saint',said that his purpose in learning and practisingmedicine was to cure rulers and their relatives ofillness, to relieve the common people of distress, andto promote health and prolong life (8). In his book,Treatises on Febrile Diseases, he harshly criticizedirresponsible physicians by pointing out the harmand hazard of malpractice among physicians who didnot diligently improve medical skills, who followedthe beaten path, who practised medicine without

care and who prescribed medicine rashly forpatients. Benevolence, honesty and sagacity werealso regarded by some as important aspects ofphysicians' moral cultivation. Dong Feng (3rdcentury AD), a famous physician in the period ofThree Kingdoms, 'treated people without anycharge. Five apricot trees were to be planted whenone was cured of a serious illness and one apricottree was to be planted when one was cured of aminor disease. Several years later, a forest of100,000 apricot trees appeared'. Each year, apricotswere exchanged for grains which were distributed tothe poverty-stricken. Over 20,000 people benefitedfrom his generosity each year (10). The phrase'warm spring in the apricot wood' has since beenused to praise the noble moral character of a physi-cian (8). Yang Quan, a physician of the Jin Dynastystressed that a physician must be benevolent,sensible and honest and must have a noble characteras well as excellent skills.The Tang Dynasty (618-907 AD) was one of the

periods of great prosperity in ancient China. Thetime was ripe for summarizing the medical ethicaltradition in the context of political, economical andcultural development. Tsun Simiao (581-682 AD),a famous physician and pharmacist, was an import-ant pioneer in the field of medical ethics in ancientChina. One of the articles in his important book,Golden Essential Recipes, is the earliest and mostfamous monograph on medical ethics. He annotatedthe title of the book by saying 'human life is moreprecious and valuable than a thousand gold piecesand one good recipe prescribed can be life-saving;therefore, the name of Golden Essential Recipes ischosen'. The medical ethical thinking of TsunSimiao was highly appreciated by both Chinese andforeign scholars. A Japanese professor onceremarked, 'Today we talk about respecting humanlife. Thirteen hundred years ago, Tsun Simiao inancient China explicitly pointed out the truth andwrote about it' (11). The only copy of the NorthSong Dynasty (960-1127) version of the GoldenEssential Recipes is carefully preserved in Japan and isregarded as 'a national treasure' by the Japanesegovernment. In his famous monograph on medicalethics, Tsun Simiao set the norm for scholarlyattitudes, style of medical practice, character cultiva-tion, deportment and academic ethics. It can be seenfrom Tsun Simiao's systematic summarization, andfrom his contribution, that Chinese traditionalmedical ethics was at that time entering a period ofmaturity and stability.

Principles of medical ethicsDuring the Ming Dynasty (1368-1644), efforts weremade to set up principles of medical ethics. LiShizhen (1518-1593) can be said to have providedthe model of integrity in medical and medicinalstudies with the re-writing of his book, Compendium

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of Materia Medica. He showed his respect for thework of others by giving references to the originalliterature. Gong Jingxian in the 16th and 17thcentury enumerated 'ten tenets for physicians andten tenets for patients' so as to co-ordinate therelationship between physicians and patients. Hiscontemporary, Chen Shigong (1555-1636) putforward Five Commandments and Ten Tenets forPhysicians (12), which is similar to present-dayethical principles for physicians.

In the Ming and Song Dynasties, some physicianswere also critics of medical ethics. They criticisedharmful tendencies in medical practice, thus demon-strating that medical ethical criticism has long beenpresent in the construction of Chinese traditionalmedical ethics.

Throughout China's long history, a rather highlydeveloped system of Chinese traditional medicalethics has emerged with well-defined basic contents.These lay down that all medical workers shouldabide by the following six tenets.

Value ofhuman lifeFirst, they should appreciate the value of life andrescue the dying and heal the wounded by all meansavailable to them. A lofty concept of the value ofhuman life was established among ancient physi-cians, as reflected in Tsun Simiao's remark that'human life is more precious and valuable than athousand gold pieces'. Tsun Simiao was also deter-mined to relieve all human beings from suffering,showing his sense of responsibility in rescuing thedying and healing the wounded. Gong Tingxian ofthe Ming Dynasty also pointed out that 'medicine isfor living people' and that 'in a physician's hand liesthe life or death of a patient'.

Second, they should care for patients' sufferingand practise medicine with honesty. Tsun Simiaomaintained that a physician should bear the sufferingof patients in mind, not his own material interests. InFive Commandments and Ten Tenets for Physicians,Chen Shigong also asked physicians to practisemedicine with integrity: they should not replaceprecious herbal materials provided by the family ofthe patients with inferior ones, nor charge the poor,and wandering monks. And what is more, he urgedphysicians to give as much financial support aspossible to poverty-stricken patients, for he believedthat no medicine could cure any person with anempty stomach. He also suggested that physiciansshould not be extravagant but should live simply. Heheld that it was much better to save money than tocharge more fees.

Third, they should diligently improve medicalskills and oppose careless styles of working. TheYellow Emperor's Canon of Internal Medicine pointedout that physicians 'should be knowledgeable aboutheaven, earth and man' in order to be qualifieddoctors. Famous ancient physicians such as Zhang

Zhongjing, Tsun Simiao and Li Shizhen were alldiligent in studying medicine and they were notafraid of difficulty and hardships. Tsun believed thata physician should concentrate thoroughly and bemost careful, and absolutely accurate, when diag-nosing a disease.

Fourth, they should act with decorum, decencyand politeness. The Yellow Emperor's Canon of InternalMedicine requires physicians to 'ask about thecustoms when entering a foreign state, ask aboutthings forbidden when visiting a household and askabout manners when practising medicine'. Thisshows that the good tradition of respecting customsand practising medicine with integrity has beenstressed since ancient times. In Rules and Regulationsfor Practising Medicine, Li Yan of the Ming Dynastywrote: 'when diagnosing a woman, an immediaterelative of hers should be invited to question thewoman about signs, the tongue and dietary habitsfirst', and 'more respect should be paid and morecaution should be given when one gives medical treat-ment to a widow or a maid'. In Five Commandmentsand Ten Tenets for Physicians, Chen Shigong pointedout that a prostitute who came to see a doctor shouldbe treated as if she was a good lady and the physicianshould not take liberties with even such a woman.These moral requirements showed the tradition ofrespect for patients, especially for woman patients, byphysicians in ancient China.

Fifth, they should acknowledge that all patients areequal before a physician. This concept was signifi-cant and progressive in a hierarchical, feudal society.In The Integrity of a Respected Physician, Tsun Simiaostressed that patients coming for treatment, whetherrich or poor, old or young, beautiful or ugly, close ordistant and Chinese or foreign, should be treated thesame as an immediate relative or a good friend. GongTingxian also criticized doctors who only liked togive treatment to the rich and neglected the poor, foracting contrary to the purpose of medicine.

Sixth, they should respect other people's achieve-ments and abide by academic ethics. Tsun Simiaosaid a physician should not be conceited andarrogant. In the Compendium ofMateria Medica by LiShizhen, The Medical Secrets of an Official by WangTao, and Classified Materia Medica by Tang Shenwei,good examples to fellow physicians were set out. InFive Commandments and Ten Tenets for Physicians,Chen Shigong also warned against arrogance andslandering and endorsed humbleness, caution,respect and tolerance. As it was customary in feudalChina that people of the same occupation despisedone another, these moral requirements showed thegreat courage of physicians in pursuing medicalethics.

Unique structureConfucianism occupied a longstanding dominantposition in ancient China and, moreover, 'from its

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goal, function and structure, it can be said to be aschool centred around ethics and morality' (1). Itcertainly exerted immense and profound influenceson the development of medical ethics in ancientChina.

Its influences are mainly and fundamentallypositive.

First, the school of Confucianism established aunique structure of moral principles with goodnessas the nuclear core confirmed by rites. This systemdid not only exert immense influences on Chineseculture, which was then in the process of civilization,but also served as the keynote of Chinese traditionalmedical ethics. In ancient China, medicine wascalled 'the craft of benevolence' or 'the craft ofsaints', representing the hope that physicians wouldact by the Confucian concept of 'benevolence' andpractise medicine by the teachings of Confuciansaints. Various rules and regulations of medicalethics contained instructions such as: 'Be benevolentand Confucian' and 'First know the logic ofConfucianism and then the logic of medicine'.These show that physicians regarded it as honour-able to know and follow Confucianism. In TheAnalects of Confucius's Fellow Villagers, it wasrecorded that Confucius's stable was burned down.Upon learning of the event, Confucius first asked ifanyone was hurt rather than asking about the horses.This story has progressive significance in a societywhere a horse was worth five slaves. Humanitarianethical thinking as embodied in the theory ofConfucianism exerted a direct effect on the conceptof the value of human life and human dignity.Physicians of various dynasties all stressed thatphysicians must be benevolent and that the purposeof practising medicine was to rescue the dying and torelieve the distressed. These principles have becomeguidelines for the practice of medicine. In practice,physicians of various dynasties all regarded it as alofty goal to be 'a respected physician of the multi-tude' and to 'relieve all human beings from suffer-ing'. It can be said that in ancient China, onlyphysicians had the highest and noblest professionalmorality and there were many folk stories praisingthe deeds and morality of physicians. All this isthanks to the influence of Confucian humanitarianethical thinking on traditional medical ethics.

Traditional medical ethics concerning theconcepts of justice and benefit were also profoundlyinfluenced by Confucian thinking. The Confucianconcept of 'justice before benefit' requires doctors togive justice priority and to regard honesty as a duty.To give justice priority means to regard saving andtreating others as one's destined duty. As ChenShigong pointed out: 'man receives orders fromheaven and should not act otherwise'. Secondly,physicians should have a self-sacrificial spirit. TsunSimiao said in effect that one should devote oneselfto the treatment of patients and should not shun dif-ficulties and hardships and should not consider one's

own loss and gain. Moreover, the 'justice andbenefit' concept of Confucianism instructed doctorsto be honest and pure and not to seek material gain.Under the influence of such thinking, many doctorsregarded practising medicine as a charitable activityand worked without seeking fame or benefit. Thelow price of herbal medicine and acupuncture forrelieving pain demonstrated a humanitarian concernaimed at ensuring that the common people hadaccess to medical resources.

Maintaining a proper relation between physiciansand patients has been consistently emphasized inChinese traditional medical ethics, which was deeplyinfluenced by the Confucian concept that 'man isborn good'. In classical Confucian writings,Confucius outlined a series of principles and normsfor showing respect for, and sympathy to, people,based on an appreciation of human values andhuman dignity. For example, 'Never do to otherswhat you would not like them to do to you', and'People within the four seas are all brothers', and 'Anoble man helps others to carry out only their goodwishes, not their evil ones'. These philosophicalteachings penetrated the hearts of everyone inancient China. These teachings require thatphysicians show respect for patients and thatpatients should choose a sensible physician andcomply with the physician by taking the medicineprescribed. Patients are also asked to receive treat-ment as early as possible and to believe in medicinerather than witchcraft. A good physician-patientrelation will be formed with respect and care forpatients by doctors and reliance on, and compliancewith, doctors by patients. Tsun Simiao askeddoctors to regard the sufferings of patients as theirown afflictions and to treat patients with profoundsympathy.

These attitudes of 'thinking about patients andthinking for patients' are a further application anddevelopment of Confucianism in medical ethics andprovide an emotional basis for establishing satisfac-tory physician-patient relationships.

Moral educationThe emphasis placed by Confucianists on moral edu-cation and moral cultivation also has direct relevancefor the promotion of traditional medical ethics andthe enhancement of physicians' moral cultivation.Many writings were available on ancient medicalethics which held that by learning Confucianism oneknows the truth and by knowing the truth onebecomes a good physician. In other words,Confucianism teaches people to promote moralcharacter by self-cultivation, which is also beneficialto the construction of medical ethics. In ancientChina, there were many examples of individuals whowere both famous physicians and famousConfucianists. The Integrity of Respected Physicians byTsun Simiao was not only regarded as a classic on

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medical ethics but also as representative ofConfucian writing on ethics. Famous physicians inancient times usually had great virtue. They taughttheir students how to be upright men before instruct-ing them to become physicians; this almost became aset pattern in the history of the development ofmedicine in China. All this demonstrates that themoral pursuit of medicine and Confucianism is con-sistent and that this consistency is deeply rooted inthe Confucian tradition, which emphasizes moralcultivation and stresses spiritual pursuit.Though Confucian culture has exerted positive

influences on the development of Chinese tradi-tional medical ethics, it also has its historical andclass limitations, which adversely influenced tradi-tional medical ethics. For example, in the longprocess of history, Confucian culture intensified theconcepts of hierarchy, loyalty and filial obedience.These Confucian concepts caused some unscientificand unreasonable norms and beliefs to spring upin traditional medical ethics. For example,Confucianism over-emphasized the value of humanlife and was overcautious about contact with theother sex. The Book of Filial Obedience said that eachand every part of the human body is contributed bythe father and mother and no damage or injuryshould be done to it. As a consequence, it was heldthat surgery and autopsy were immoral. Moreover,the superior position of men over women and theconcept that private contact between men andwomen was deemed improper were strengthened bythe development of Confucianism. Some medicalethical regulations stipulated that a woman withoutcompany should not be treated and that a physiciantreat his women patients over a curtain. These ruleswere neither advantageous to women nor convenientfor physicians. Indiscriminate pursuit of 'goodness'can only lead to actual 'evil' and as a consequence,the norms ofmedical ethics may be unscientific (13).Furthermore, some Confucian scholars took theconcept of 'valuing righteousness and despisingbenefit' to an extreme. Such Confucian sayings wereoften quoted as: 'Great men pursue moral principlesrather than food ... and worry about moralprinciples rather than poverty', and 'Great menpursue what is right; petty men pursue what isprofitable'. Righteousness and benefit, and moralvalue and material interest were set against eachother. As a result, goals were often unreachable andnorms were often contradictory in medical ethics.Finally, the Confucian tradition of moral educationand spiritual pursuit was developed into an idealistphilosophy during the Song and Ming Dynastieswhich reduced the practicality and applicability oftraditional medical ethics.

III. The role of Confucian culture in theconstruction ofmodern medical ethicsFrom the perspective of history, Confucianism is

neither a static system nor a meaningless antique inthe contemporary world. It is an open system thatmoves forward with social development. InSingapore, Confucian moral education is systemati-cally being carried out under the leadership of thegovernment. Some Japanese enterprises also appre-ciate the role of Confucianism in improving businessoperations. In the Selected Works of Mao Zedong,Confucian sayings were quoted over 50 times. Theseexamples clearly demonstrate that correct evaluationof the position of Confucian culture in our history,and separation of the essence from the dross inConfucianism, are of significance in the constructionof spiritual civilization as well as in that of medicalethics.

At present, with the rapid development ofmodernscience and technology, new methods are createdand new wonders are wrought in medicine, but thesealso bring about new contradictions in medicalethics. Are our efforts to enhance the quality of lifeby modern reproductive techniques worthwhile? Iseuthanasia for patients with terminal illness appro-priate? Do the new techniques such as artificialfertilization, test tube babies, organ transplantation,behaviour control and genetic engineering posechallenges to human dignity? These problems haveposed dilemmas for many concepts of traditionalethics. With the achievements in biologicalengineering, man is once again put in a perplexingsituation (13). Many traditional ethical concepts arebeing reviewed and many new notions have comeinto being. Jean Davies, Chair of the World ActiveVoluntary Euthanasia Association, remarked duringher visit to our university that: 'Man's thinking isever changing. My grandmother's contemporariestalked about money; my mother's talked about sexand ours are now beginning to talk about death'.How to keep continuity by inheriting and perpetuat-ing the essence of traditional medical ethics and howto renew medical ethics is a very serious question.Confucian culture, which has played an immenselyimportant role in the formation and development oftraditional medical ethics, also needs objectiveappraisal and amendment so that Chinese ancientculture may play a proper role in the construction ofmodern medical ethics. Four things need to be done.

1. The Confucian tradition which emphasizesmoral education and moral cultivation should bemodernized and promulgated so that people may bestrengthened by the concept that the construction ofspiritual civilization should be highly regarded in amaterially developed civilization. As part of the con-struction and formulation of medical ethics, lawsand regulations should be drawn up and noble moralcharacter as shown by physicians in practisingmedicine should be endorsed, while misconductshould be disciplined or punished. Medical ethicaleducation and practice and medical ethical evalua-tion should be integrated into the framework ofmedical education and medical practice.

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246 Chinese Confucian culture and the medical ethical tradition

2. The Confucian concepts of benevolence,righteousness and benefit, human value and filialobedience, which show historical limitations, needto be reconstructed. The essence of these conceptswhich will promote the development of medicineand help co-ordinate interpersonal relations shouldbe kept, so that Confucianism can serve medicineand the ancient can serve the present. In the process,we should note the differences or contradictions inmany Confucian concepts and make suitableexplanations. For example, according to Confucianculture, active euthanasia is not benevolent andpassive euthanasia is not good. If we look to thefuture and renew Confucian concepts about thevalue of human life and benevolence, it will behelpful in renewing people's ideas and thinking.

3. Such Confucian concepts as nobles beingsuperior to the common people and men superior towomen, should be completely discarded so as toadapt to social progress and development inmedicine. In some remoter parts of China, negativeideas about birth and mysterious notions aboutsexual medicine are related to outdated notions inConfucian culture.

4. We should learn from fellow scholars in foreigncountries. We ought to introduce new medicalethical theories into China. We should also attachimportance to: the enhancement of the quality of life;how best to safeguard the environment, and the needto carry out investigations into the difficult medicalethical problems arising from high technology.Moreover, the medical legal system, the supervisingsystem and punitive measures should be in keepingwith international norms. This will be a great help inthe construction of Chinese modern medical ethicsas well as in the reforming of the health system.

Guo Zhaojiang is Professor in the Political Department

at The Fourth Military Medical University, Xian in ThePeoples'Republic of China.

References and notes(1) Luo, G. A study on Confucian ethical thinking.

Literature and history 1988: Jun.(2) Luo, G. Annotation of ethical terms. Beijing: People's

Publishing House, 1986.(3) Zhang, C. Historical evolution ofConfucianism and its

functions. Jrournal ofphilosophy and sociology 1988: Jan.(4) Wen, K. On the ethical thinking of Confucian

humanism. Journal of Tianjin University 1987: Feb.(5) Zhang, G. Pros and cons of theories on benevolence

and benefit of Confucianism, Mohism, Taoism andLegalism in early Qin dynasty. Xinhua reader's digest1992: Jan.

(6) Qu, Y. On Mencian viewpoints of value. Xinhuareader's digest 1992: Sept.

(7) Zhong, Z. Confucianism in substitution for religion.Xinhua reader's digest 1992: May.

(8) Encyclopedia of Chinese medicine: history of medicine.Shanghai: Shanghai Science and TechnologyPublishing House, 1987.

(9) According to the Encyclopaedia of Chinese medicine:history ofmedicine (see reference (8): 167), an Americannamed I Veith got his doctorate degree by virtue ofhaving translated The yellow emperor's canon of internalmedicine (1949). Scholarly works like World outlook andprinciples concerning astronomy, universe, physics andphi-losophy of the Chinese by a British man named AlfredForke (1925), Chinese medicine by an American namedWilliam Morse (1934), and Plain questions - basics ofChinese medicine, by another American named MDawson, all refer to the contents of this great book.

(10) See reference (8): 88.(11) Sun, P. Master pharmacist Tsun Simiao. Shaanxi

People's Publishing House, 1983.(12) Guo, Z. New edition of medical ethics. Lanzhou:

Lanzhou University Press, 1988.(13) Guo, Z, et al. An outline of medical ethics. Shaanxi

Science and Technology Publishing House, 1991.

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