载《中国基督教研究》2016年第6期
网址：https://ccspub.cc/jrcc/article/view/317/511
Gee Y Lowe, Ph.D.
China Evangelical Seminary North America
Abstract: With the rapid advance in technology, the world is confronted with a new set of ethical challenges. China, in the height of her modernization project, certainly would feel the crunch of such onslaught. This paper examines Confucian ethics in light of a major, bioethical approach of the West.
Since its emergence some thirty/forty years ago, biomedical ethics in the US has developed several approaches. The principlist is one such approach using moral principles to address ethical issues. In particular, the approach proposed by Beauchamp and Childress has become influential. Their coauthored text, Principles of Biomedical Ethics, is regarded as “a standard text” in biomedical ethics and “a virtual bible to some practitioners.” [1] Examining Confucian ethics in the grid of Beauchamp and Childress’ principlist approach will yield significant insights for formulation of a new biomedical ethics in China.
Beauchamp and Childress’ Principlist Approach
Beauchamp and Childress’ approach centers on the adjudication of four moral principles believed to have their source at common morality, hence, the name Four-Principle Approach. The four principles are: 1. Respect for Autonomy, 2. Nonmaleficience, 3. Benevolence, and 4. Justice. Beauchamp and Childress believe that they are cherished common sense principles which find universality across theories and diversity of traditions. However, in the formulation of Beauchamp and Childress, they are not absolute principles, and there is not a lexical order that prioritizes them. They are what Beauchamp and Childress would depict as "prima facie" principles, which mean that, in ordinary circumstances, the principles are binding, and do dictate a judgment of right and wrong on certain actions. However, they are subject to revisions or to being overridden if in conflict with another principle in a particular circumstance.
The Principle of Respect for Autonomy stipulates that a person should be entitled to freedom of self-rule or self-governance. The principle of respect for autonomy is therefore to treat persons in a way enabling their autonomous actions or choices. Disrespect for persons' autonomy would then involve actions or attitudes that diminish, ignore, or demean their autonomy and consequently deny them minimal stature as persons. Beauchamp and Childress acknowledge two sources for this principle: Emmanuel Kant and John S. Mill.
The scope of the Principle of Respect for Autonomy only covers persons who are autonomous. Nonautonomous persons, like infants, or mentally retarded persons, are not treated the same way as normal, autonomous persons. Therefore, interpretation or determination of whether a person is autonomous becomes a major concern in application of this principle.
The second and third principles, Nonmaleficence and Beneficence, are similar concepts. Actually beneficence entails Nonmaleficence. We can for convenience and space consideration present them together here (and in the rest of the paper). Nonmaleficence is a prominent concept in the Hippocratic tradition, expressed in the very well-known maxim Primum non nocere or “Above all (or first) do no harm.” Beneficence refers to actions done to benefit others and not just to an avoidance of harm to them. In formulating rules for both principles, Beauchamp and Childress get down to many practical issues concerning whether to withhold or withdraw treatments for patients, “ordinary vs. extraordinary treatments,” intended vs. merely foreseen effects of a particular treatment, etc. We can see the practicality of distinguishing these two principles in the urgency of the emergency room. After all, when a physician is contemplating a particular treatment for a patient, before any thought of benefit, her first consideration should be: Will the treatment inflict any harm to the patient? However, in a philosophical, conceptual discourse of ethics like what we are doing, we can temporarily collapse the two principles under one heading: Beneficence.
One is surprised to find the many issues regarding the Principle of Beneficence despite its universal appeal. One of the major issues concerning the principle is paternalism. Beauchamp and Childress define paternalism to be "intentional nonacquiescence or intervention in another person's preferences, desires, or action with the intention of either avoiding harm to or benefiting the person."[2] Will the physician’s action, in his desire to benefit the patient, overreach his bound and become paternalistic, thereby diminishing his patient as a person? This is a very important issue in the Western cultural fabric that celebrates individualism.
The fourth is the Principle of Justice. According to Beauchamp and Childress, "one who has a valid claim based in justice has a right, and therefore is due something." "An injustice therefore involves a wrongful act or omission that denies people benefits to which they have a right or fails to distribute burdens fairly."[3] This is considered the "formal" principle of justice,
The "material" principles of justice further specify the relevant characteristics, which are also called "the relevant properties" for equal treatments. Beauchamp and Childress embrace the contractarian theory of justice as equal opportunity and fairness proposed by Norman Daniels derived from John Rawls. They favor a just and fair distribution of a decent minimum of health care to people not based on the lotteries of life, such as IQ, gender, wealth or position.
A Methodology Matter: Convergence Across Ethical Theories
If one takes a closer look at the methodology of the FPA of Beauchamp and Childress, it is not difficult to see a reflection of the cultural and philosophical characteristics of our age. As the postmodern age challenges the reign of science as the only sure path to knowledge, the FPA rejects the supremacy of any single ethical theory that can governs human behaviors in a consistent and systematic manner, particularly those in biomedical ethics. As stated above they are doubtful of any unified foundation for bioethics.
Therefore, the FPA does not claim to be an ethical approach unified by a single theory. However, it would be inaccurate to characterize the Four-Principle Approach as a complete rejection of theoretical ethics. Their rejection concerns only the supremacy of any one single theory. They readily acknowledge the many strengths (as well as the weaknesses) across diverse ethical theories and traditions. As a matter of fact, in searching for an adequate and practical solution to biomedical moral dilemmas, Beauchamp and Childress have recognized a so-called "convergence" of mid-level principles that are more or less common among diverse ethical frameworks, e.g. principles of love, compassion, and justice, etc. And they believe that the four principles (summarized here) are such mid-level principles that can be found across diverse moral systems. They find that differences among ethical theories are overstated. In a given situation, it is their claim that different theories produce roughly similar action guides and similar descriptions for different roles of characters in ethics. Hence, no matter which ethical theory that one starts with, they conclude: "It is possible from several of these standpoints to defend roughly the same principles, obligations, rights, responsibilities, and virtues."[4] They term this phenomenon as "convergence across theories."
It is quite true that a convergence phenomenon does exist among ethical theories. That is why we may see a Christian and a Buddhist both defending actions on the basis of a similar principle, let’s say, of love, or a Muslim and a Hindu on a similar principle, perhaps, of justice. However, resultant actions can still be very diverse depending on the ethical systems that produce them. Therefore, it is reasonable to assume that additional factors do go into the decision making process besides these convergent mid-level ethical principles.
Nevertheless, the convergence phenomenon does provide a great starting point for dialogue among different ethical systems. The similarities as well as differences may enable each system to understand and learn from the others. It is from this standpoint that we are to examine the convergence areas of Christian ethics, Classical Confucian ethics and the FPA of Beauchamp and Childress.
Convergence with Christian Ethics
If one is in general familiar with ethical principles espoused in Christianity, it is not difficult to see the area of convergence of Christianity with the FPA in terms of ethics. The well-known verse, Micah 6:8, often cited by ministers to their Christian congregations as moral and ethical instruction reveals such convergence. Micah 6:8 is rendered by the New American Standard Bible as follows:
“He has told you, O man, what is good;
And what does the Lord require of you
But to do justice, to love kindness,
And to walk humbly with your God?” (Micah 6:8)
From this simple verse, one can immediately find two convergent principles. Christians and their Jewish counterparts, by virtue of this verse, are called to do justice and love kindness, the principles of justice and beneficence, respectively, in the scheme of Beauchamp and Childress. This should not come as a surprise, as Jesus is known for his compassion for people and justice for the poor. He is also known for his healing ministry on Earth.
There is one healing story of Jesus recorded in the Bible that most exemplifies the FPA of Beauchamp and Childress. The passage is recorded at John 5:1-14, where an invalid of 38 years found at the Bethesda Pool near Jerusalem had a healing encounter with Jesus. The Bethesda Pool was known for its healing power and its five colonnades were filled with disabled people, seeking miraculous healing by striving to be first to hit the pool when the water was stirred. Some manuscripts include indication that “From time to time an angel of the Lord would come down and stir up the waters. The first one into the pool after each such disturbance would be cured of whatever disease they had. “ (John 5:4)
It was in this setting Jesus’ healing encounter with the paralyzed man took place. John has juxtaposed the great reputation of the Bethesda Pool as a healing institution with the paralytic man whose ailment was left unattended for 38 years. It is interesting to note how John had recorded the story. We don’t have much information about the patient. John simply states, “One who was there had been an invalid for thirty-eight years.” (John 5:5) His name and ailment were not specifically mentioned. However we know that he had been afflicted with whatever it was for 38 years. John’s intention by recording this story in this manner is obvious. Regardless who he and what the ailment was, a reputed healing institution with an unattended patient of 38 years is an oxymoron, a grave social and medical injustice.
Here came Jesus.
John continued with the story:
When Jesus saw him lying there and learned that he had been in this condition for a long time, he asked him, ‘Do you want to get well?’ ‘Sir,’ the invalid replied, ‘I have no one to help me into the pool when the water is stirred. While I am trying to get in, someone else goes down ahead of me.’ Then Jesus said to him, ‘Get up! Pick up your mat and walk.’ At once the man was cured; he picked up his mat and walked. The day on which this took place was a Sabbath, and so the Jewish leaders said to the man who had been healed, ‘It is the Sabbath; the law forbids you to carry your mat.’ But he replied, ‘The man who made me well said to me, ‘Pick up your mat and walk.’ So they asked him, ‘Who is this fellow who told you to pick it up and walk?’ The man who was healed had no idea who it was, for Jesus had slipped away into the crowd that was there. (John 5: 6-13)
The Principle of Respect for Autonomy
As the story unfolds, Jesus entered the pool area and noticed the paralytic man immediately and asked him whether he wanted to get well. One may wonder why Jesus asked such an obvious question. Isn’t that redundant? Yet in light of the FPA, this is respect for the patient’s autonomy, the first principle in Beauchamp and Childress’ system. The patient, though ill and very much desiring healing, is an autonomous agent who holds absolute rights to his own destiny, including the decision to be healed. As stated above, the principle of respect for autonomy is treating persons in a way enabling their autonomous actions or choices. Jesus by asking that obvious question was exactly rendering that respect for the patient and obtaining his consent to be healed. One may further notice, in the whole healing process for the patient, Jesus continued to leave room for the patient to exercise autonomous actions or choices. Jesus told the invalid to “Get up! Pick up your mat and walk.” The invalid ‘s healing apparently was contingent on these actions. The invalid had to be willing to “get up, pick up the mat and walk. “ In the process, the patient had been affirmed as an autonomous person.
A word of caution is in order at this point, lest we overstate the degree of convergence of the two systems concerning this principle. It is also true that some view Christianity, as a religious institution, more on the paternalistic side. The term “paternalism” originates from the political realm, where the principle and practice of paternal administration or governance of a people or community is similar to a father’s relationship with his children. There are two distinctive features of paternalism. One is the paternalist's claim of acting beneficially, and the other is that the paternalist usually makes all or some of decisions for the people or person to whom he is administering in relation to their welfare. In the biomedical context, Beauchamp and Childress define paternalism to be "intentional nonacquiescence or intervention in another person's preferences, desires, or action with the intention of either avoiding harm to or benefiting the person."[5] Paternalistic behavior is therefore diametrically opposed to the concept of respect for autonomy. Because of the special emphasis on obedience to authority, paternalism can be a concern in the Christian church.
In this light, the FPA’s principle of respect for autonomy can be a healthy safeguard against such paternalism. On the other hand, a healthy respect for the authority can be nurtured from the Christian principle of obedience for the Chinese patients. A delicate balance needs to be struck for the patient-physician relationship considering both principles.
The Principles of Nonmaleficence and Beneficence
Of course as the story goes, the patient was miraculously healed, which demonstrated Jesus’ compassion for him, a patient who had been neglected for 38 years in the healing institution of the Bethesda Pool. As far as Jesus’ healing ministry goes, it is apparent from the record of the Gospels that it occupies a chief place in Jesus’ overall ministry. Some scholars in the past may question the miraculous nature of many of Jesus’ healing episodes, but Jesus’ compassion for the sick is beyond criticism, and the 2nd and 3rd principles of Beauchamp and Childress’ system converge well here with the tenets of Christianity.
The Principle of Justice
The principle of justice, the fourth principle of the FPA, also carries significant import in the invalid’s healing story. In the pen of the Apostle John, the Bethesda Pool, though reputed for its healing prowess, was nevertheless an unjust healing institution. Only the stronger patients, those who could get to the pool first when the water was stirred, received healing. The weaker ones, like the paralytic man, were plainly out of luck, and had to do without treatment or attention for possibly 38 years. That certainly was the case for the paralytic man until he met Jesus, a healer who was sensitive and quick enough to spot the neediest one among the large crowd. And this certainly was Jesus’ ministry pattern throughout his life on earth as recorded in the Gospels. In the beginning of his earthly ministry, teaching in the synagogue, Jesus compared himself to the suffering servant depicted by the Prophet Isaiah (Luke 4:18-19):
"The Spirit of the Lord is upon Me,
Because He anointed Me to preach the gospel to the poor.
He has sent Me to proclaim release to the captives,
And recovery of sight to the blind,
To set free those who are oppressed,
To proclaim the favorable year of the Lord."
Justice for the poor and oppressed was certainly in the forefront of his mission on Earth.
Although Beauchamp and Childress never claim Christianity as a direct source of inspiration, this short exercise demonstrates clearly the high level of convergence of the two ethical systems in terms of principles. However, ethical decisions are not made from principles alone. The reason why the convergent principles are called mid-level because there are more fundamental dimensions that influence our moral behaviors. One very important such dimension is our respective world-views. What constitutes justice in the Christian world-view is probably very different from one viewed from a humanistic perspective. Currently, a lot of literatures have been written and many debates are going on about what constitutes justice. Similarly, different world-views can exact different limits on obligations of an individual or society’s sense of compassion for others. Nevertheless, principles of convergence serve as common grounds and facilitate dialogues across diverse ethical systems.
Convergence with Classical Confucian Ethics
Confucianism has been recognized for its hegemonic influence on Asian cultures. Its role in shaping China’s medical ethics in the past has also been well known. As China moves rapidly toward modernization, Chinese leaders recognize that the progress must also be founded on a harmonious society with just and moral principles. Just as this paper is written, an article published by The Wall Street Journal reporting on the findings of a study of life expectancy in China[6]. The study shows a grave discrepancy of life expectancy numbers between the well-developed regions and the less-developed ones. “ People in less-developed regions… have double the burden of infectious diseases…The chasm in regional results shed lights on economic growth, as well as income and health inequalities in China,” the article reported. Economic and health inequalities are already becoming major social issues facing China. Can Confucian ethics again, as in it’s long history, holds sway in shaping the moral fabrics, particularly, in terms of biomedical ethics in China in the 21st century? This is not only an interesting but urgent question worthy of exploration.
Beauchamp and Childress’ Four-Principle approach is widely accepted in the West for its comprehensiveness and applicability. The author believes it will be instructional to examine the classical Confucian ethics through the grid of the Four-Principle approach to uncover any common grounds or differences between the two systems. The Christian corrective to the FPA useful in the framework of Confucian ethics will also be noted.
The Principle of Respect for Autonomy
Confucian medical ethics has great respect for human life. Its communitarian and hierarchal nature has also been well documented.[7] At first glance, one wonders if it has the resource necessary to promote an ethics that can serve a new China increasingly under Western cultural influence, for some of these aspects of traditional Confucian ethics do seem to be diametrically opposed to the very Western concept of the supremacy of the value of the individual. Given this cultural backdrop, one may want to ask: Do we even need to be concerned with the concept of autonomy so alien to the majority of traditional Chinese? In formulating a modern biomedical ethics, some Chinese ethicists appear to embrace the traditional communitarian and hierarchical flavor of Confucian ethics, and favor the dropping of the alien concept of autonomy.[8] Some argue otherwise.[9] In my opinion, considering the significant influence of the Western cultural currents in China, and the rise of educational level of average Chinese patients, it probably is best to maintain a middle ground, where respect for autonomy will be honored to a certain degree. If that is the position we want to take, it will be worthwhile to explore the issue of individual autonomy in Confucian ethics.
Joseph Chan in his article “Moral Autonomy, Civil Liberties, and Confucianism” recognizes the urgency of such discussion. He terms it “one of the most challenging issues that must be faced”[10] in developing a viable Confucian ethics for contemporary Chinese communities. He distinguishes between the concepts of moral autonomy and personal autonomy. In this scheme, moral autonomy only calls for the minimal requirements of voluntary endorsement and reflection of morality. However, a “personally autonomous” individual must be able to go beyond that and subject himself to no moral authority other than that validated based on reason or a “radical free expression of the individual’s will.” [11] He maintains that while moral autonomy can be found in Confucian ethics, personal autonomy is incompatible with it. [12] While his conclusion may be subject to debate, scholars do in general agree that “The central problem in self-cultivation [for Confucians] is not the proper exercise of free choice, as is hypothesized in so much of Western ethics.”[13] If that is the case, a second question may be posted: Can we find any resource in classical Confucianism that can remotely support the concept of personal autonomy?
Even though Confucianism in general has been seen as failing to emphasize an individual’s proper exercise of free choice, we believe there is some resource in classical Confucianism that supports the concept of personal autonomy. In the Analects, Confucius was talking to four of his disciples: Tselu, Tseng His, Jan Chiu and Kunghsi Hua. Confucius urged them to share their aspirations. Tselu, Jan Chiu and Kunghsi Hua all shared their political ambitions, all of which were considered proper goals promising young men like them should aspire to. However, when it was Tseng ’s turn, after putting the instrument he just played, he said, “My aspiration is different from theirs.” “It doesn’t matter,” said Confucius, “we are just trying to find out what each would like to do.” Then Tseng continued, “In late spring, when the new spring dress is made, I would like to go with five or six grown-ups and six or seven children to swim in River Yi, and after the swim we can just enjoy the breeze in the Wuyu woods, and then sing on our way home.” Confucius heaved a deep sign and said, “You are the man after my own heart.”
This is one of the rare instances when Confucius and his disciples are seen simply expressing the desires of their own heart. It is also amazing to see how the Master actually encouraged Tseng’s expression of his seemingly selfish and not so conventional aspiration. Confucius’ respect for his pupil’s autonomous aspiration can indeed be regarded a great resource for the principle of respect for autonomy. Respect for patient’s autonomy is occupying an increasingly important place in biomedical ethics, or in ethics in general. Given China’s rapid modernization and the rise of patients’ level of education, we believe any new formulation of biomedical ethics in China will need to address this principle to a certain degree.
In this respect, as noted above, Christianity does provide a more balanced perspective. Within the tenets of Christianity, obedience to authority is deemed a virtue. However, every human being is created in God’s image, whose freedom is ultimately worthy of respect.
The Principles of Nonmaleficience and Beneficience
Confucian ethics is known for its Principle of Jen (or Ren， 仁), which encompasses the concept of compassion for people. This is the essence of Confucianism. A few quotes from the Analects can demonstrate this: "Now the man of perfect virtue (jen), wishing to be established himself, seeks also to establish others; wishing to be enlarged himself, he seeks also to enlarge others.” Fan Ch'ih asked about benevolence (Jen). The Master said, "It is to love all men.” And the hallmark Confucian quote denotes clearly of such an empathetic spirit: “Not to do to others as you would not wish done to yourself” Therefore Confucian ethics has rich resource to support this principle. As a matter of fact, Guo observed in his article, “A lofty concept of the value of human life was established among ancient physicians.” Some was “determined to relieve all human beings from suffering, showing his sense of responsibility in rescuing the dying and healing the wounded.” This was so, because “traditional medical ethics…were also profoundly influenced by Confucian thinking. “[14] In “The Confucian concept of Jen and the Feminist Ethics: A Comparative Study,” Chenyang Li also concludes that Confucian ethics “is a care-perspective ethics” [15] To be sure, there is no lack of compassion in Confucian ethics. However, as noted above, the lack of emphasis on respect of personal autonomy in Confucian ethics may lead to one concern: paternalism. One of the major issues in biomedical ethics is the priority between the principle of respect for autonomy and the principle of beneficence. In some instances of health care situations, the two principles may come into conflict (e.g. physician-assisted suicide, euthanasia, etc.), and at times, the physician may take liberty to override all or some of the decisions of the patients in the belief that he is acting beneficially. The balance for the principle of beneficence is therefore a proper respect of patients’ rights and autonomy as a person.
The Principle of Justice
The main concern in Beauchamp and Childress’ approach regarding this principle is distributive justice. The concern is how to distribute health care fairly across society. The Wall Street Journal article cited above actually reveals a problem with distributive justice in health care in China today. Beauchamp and Childress believe everyone, regardless of his/her socio-economic status, should be entitled to what they call “a decent minimum” of health care. Regarding this, there should be ample resources in classical Confucianism that can be drawn to support this concept. As a matter of fact, traditional Chinese medical ethics summarized by Guo reflects a strong conviction in this principle. In “Five Commandments and Ten Tenets for Physicians”, Chen Shigong asked physicians to “practice medicine with integrity…[and not] charge the poor, and wandering monks.”[16] Guo further states, “Traditional medical ethics concerning the concepts of justice and benefit were also profoundly influenced by Confucian thinking…To give justice priority means to regard saving and treating others as one’s destined duty.”[17] However, traditional understanding may note the tension with the female gender in Confucianism. This indeed may pose an obstacle for the formulation of a contemporary Confucian biomedical ethics. In posing a question, “[I]s Confucianism a care ethics that has oppressed women?” Chenyang Li’s answer provides a great defense for classical Confucianism. Li’s conclusion regarding this issue is worth noting: “If by Confucianism is meant Confucianism after Tung Chung-shu’s yin-yang philosophy, the answer to this question is definitely affirmative. If…genuine Confucianism is [that] before Tung, then there is no evidence that [it] was really oppressive to women.”[18] If collaborated, this conclusion can expand the horizon for Confucian ethics to play a key role in biomedical ethics in the 21st century despite apparent obstacles.
The Implications of the Convergence Phenomenon
The Four Principle Approach of Beauchamp and Childress has won wide acclaim in the field of biomedical ethics. They reject the idea of an overarching theory that can govern human behaviors in a consistent and systematic manner, but confirm a large degree of convergence across ethical theories. Exploratory comparisons of Christian and Confucian ethics with the Four Principle Approach do show a good degree of convergence, at least at the level of principles. The implication of such convergence means that the FPA can server as a broad framework for China to explore their version of Biomedical ethics, perhaps, with corrective resources coming from classical Confucianism and Christianity. The convergence can also serve as common grounds and/or starting points for dialogues among diverse ethical systems. For example, the exercise here has shown that classical Confucianism is limited in resource regarding the concept of respecting personal autonomy, which is becoming important in a society under rapid modernization. However, as noted, the concept is not totally absent and can be developed to meet the challenge of the time. Christianity can also provide the needed balance and corrective to both systems, if deemed appropriate.
[1] E. R., R. Hamel DuBose and L. J. O’Connell, A Matter of Principles? Ferment in US Bioethics, (Pennsylvania: PTI), 1994, I
[2] Tom L. Beauchamp and James F. Childress Principles of Biomedical Ethics, 4th ed. (New York: Oxford University Press), 1994, 274.
[3] Ibid., 327.
[4] Principles of Biomedical Ethics, 110.
[5] Principles of Biomedical Ethics, 274.
[6] Laurie Burkitt, “Chinese People Are Living Longer , New Study Shows”, China Realtime, The Wall Street Journal, 10/27/15
[7] Z. Guo “Chinese Confucian Culture and the Medical Ethical Tradition,” J Med Ethics, V.21 no.4 Aug.1995, 239-46
[8] Michael Cheng-tek and Chung Seng Lin “Developing a Culturally Relevant Bioethics for Asian People,” J Med Ethics 2001;27;51-54
[9] Guo flatly states, “Such Confucian concepts as nobles being superior to the common people and men superior to women, should be completely discarded…” p.245
[10] Joseph Chan, “Moral autonomy, Civil Liberties, and Confucianism,” Philosophy East and West, Jul 2002; v. 52; Iss. 3; 281-310
[11] Ibid, 282-3
[12] Ibid. 284-5
[13] Donald Munro as quoted by Chan, 292
[14] Guo, 241-2
[15] Chenyang Li, “The Confucian Concept of Jen and the Feminist Ethics of Care: A Comparative Study,” Hypatia, Winter 1994, V.9, Iss. 1,70-85
[16] Guo, 242
[17] Ibid.
[18] Li, 80
