Vivian-Lee Nyitray. Bioethics. Editor: Bruce Jennings, 4th Edition, Volume 2, Macmillan Reference USA, 2014.
Confucianism draws its name from the Latinized honorific title of its founder, Kong Chiu, or Kong fuzi (562-479 B.C.E.), an independent scholar and unsuccessful political adviser who believed moral self-cultivation and the practice of ritual to be the cornerstones of an ideal society. Initially espoused by no more than a few dozen students, Confucius’s teachings—expanded and significantly elaborated over time—ultimately became the dominant sociopolitical ideology of China and of Sinitic-influenced cultures of East and Southeast Asia. Other traditions, notably Mahayana Buddhism and Daoism, successfully rivaled Confucianism for state support over the centuries, but none ever seriously threatened the Confucian tradition’s pervasive cultural dominance. Carried beyond its historical Asian boundaries by merchants, laborers, and refugees, Confucianism also maintains a strong hold on diasporic Chinese, Korean, Japanese, and South Vietnamese populations.
In considering the complexities of the Confucian tradition, the following must be borne in mind: (1) the tradition is not monolithic, that is, historical era, regional variation, and differential class appropriation inform Confucian practice; (2) the tradition does not exist in conceptual isolation, that is, within any given local culture at any particular historical moment Confucianism has always been observed by individuals as part of a constellation of personal and cultural practices; (3) although there is a sense of authority residing in the canonical texts and commentaries of the Confucian classics, there is no central governing body, no clergy, and no history of religious jurisprudence within the tradition to dictate orthodoxy or legislate orthopraxy; and (4) there is neither a concept of evil nor an absolute dichotomy between right and wrong as understood in Abrahamic monotheisms; rather, it is ignorance, self-delusion, and a tendency to gratify selfish desires that pose the greatest obstacles to moral improvement. Of particular relevance to contemporary bioethical concerns is the absence of notions of personal rights. In the Confucian view humans are defined by their capacity to fulfill relational duties and responsibilities—particularly in the context of an extended family—rather than by any sense of autonomy or inherent possession of individual rights.
Origins of the Classical Tradition
Core concepts are found in brief statements attributed to the Master himself, recorded by others in the verses of the Analects (Lunyu) (Brooks and Brooks 1998), the Great Learning (Daxiie), and the Doctrine of the Mean (Zhongyong), all of which contain significant interpolations and emendations. As received tradition, however, the aphorisms ascribed to Confucius and his early followers continue to exert considerable authority. At the heart of the Confucian vision is the sense that an individual becomes truly human only through a deliberate process of moral education. The cultivation of virtues and their expression in ritual forms yields a junzi (gentleman, or, in early twenty-first-century terminology, a perfected person) who stands ready to fulfdl the responsibilities of living in concert with others and of establishing a peaceful, just, and aesthetically pleasing society. Ritual without virtue is ornament without substance; virtue without ritual can lead to unbounded good intentions that may ultimately do harm.
Confucian society is built upon a set of five reciprocal relationships, each of which is characterized by particular virtues and specific responsibilities: (1) ruler-subject, (2) parent-child, (3) husband-wife, (4) older-younger (brothers), (5) friends. Confucius’s primary concern was with the creation of a stable and prosperous state, but he understood that it was the family that would ultimately produce the individuals dedicated to establishing his ideal society. Of the five relationships therefore, three are located within the family; of these the most important is that between parent and child. For having given life, one’s parents are owed an enduring debt of gratitude—an obligation that extends even beyond the temporal boundaries of this lifetime. The practice of filiality is therefore the starting point for Confucian moral cultivation, and the family is the foremost focus of religious practice.
An individual’s relationship with a person outside the family is determined by the interlocking considerations of age, social and educational position, gender, and degree of professional and personal connection—all of which determine relative seniority and significance and thus the degree of deference and potential obligation owed. However, how one acts within the relationship is far more flexible and less hierarchical than might be assumed. Much has been made in Western philosophical literature of the Golden Rule found in Analects 5:12 and 12:2, but Confucius himself indicated that his ethical teachings were bound by a “single thread” comprising two strands, zhong (centeredness) and shu (reciprocity) (Analects 4:15). These terms refer to a dialectical process that requires that one first center oneself in the relationship at hand, clearly understanding its attendant responsibilities and privileges, and then imaginatively take the other’s position in the relationship. Only then, from this enlarged and empa-thetic perspective, does one act in full awareness of the consequences of one’s actions for the other person. Ideally such reflexive behavior serves to mitigate abuse of power in hierarchical relationships; in reality it also fosters paternalism.
In the centuries after Confucius’s death, new questions arose to challenge the tradition. A particularly vexatious problem was how to account for people’s varying capacities to learn (or even to want to learn) to become truly human. The ensuing debate was ultimately settled in favor of the view espoused by Mengzi (Latinized as Mencius, 372-289 B.C.E.). According to Mencius, all people possess the four seeds of humaneness, righteousness or duty, propriety, and wisdom. If nourished properly through environment and education, these seeds mature into the moral attitudes and ritual behaviors of true humanity. It is worth noting, however, that extrapolation from this claim yields the conclusion that those who do not exhibit these seeds or their outgrowth are not entirely human—a conclusion with potentially troubling ramifications in discussions of eugenics, capital punishment, euthanasia, and the harvesting of organs for transplantation.
The Han Synthesis
After China was united under the relatively stable administration of the Han dynasty in 206 B.C.E., training in Confucian principles was established as the basis for participation in the state’s meritocracy. Over the course of the Han (through 221 C.E.), Confucianism’s purview expanded beyond philosophical-political discussions of virtue and ritual to encompass cosmological theories derived from ancient divination forms and from yin-yang and the so-called Five Elements systems. The goals were to discern macrocosmic and microcosmic correspondences and then to regulate human actions to ensure harmony with heaven and earth. Although many of the theories incorporated into this syncretic Confucian cosmology are frequently associated with Daoism, they are more accurately described as belonging to a presectarian worldview that underlies all Chinese religio-philosophical traditions.
The hexagrams of the I Ching (Book of Changes) provided glimpses of the flow of natural processes, especially qi, the animating “breath” of the cosmos. The alternation of yin (darkness, passivity, decay, emotionality, and femininity) and yang (light, activity, growth, rationality, and masculinity) underscored notions of complementarity. The Five Elements (fire, water, wood, metal, and earth) explained a thing’s inherent characteristics and its patterns of growth and decline. Elaborate correspondences were constructed among these classificatory systems, such that hours of the day, seasons of the year, foods and tastes, colors, sounds, organs of the body, stages of life, heavenly constellations, and virtually all human activities could be mapped and harmonized. A dislocation or inappropriate item in any one part of the schema would lead to disharmony and inaus-piciousness elsewhere. In the political realm disharmony breeds revolution; in the personal realm disharmony breeds illness. Thus the goal of Chinese medicine is to restore the natural balance of one’s internal environment and to harmonize it with external environmental circumstances. This requires that a patient’s food, medicines, and therapies be dictated not only by symptoms but also by individual psychophysiology and local environmental factors, such as season of the year. In the Confucian view maintaining one’s good health is dictated by filial responsibility, as one’s parents should have no cause for worry.
Neo-Confucianism
After the collapse of the Han, China fragmented into several smaller kingdoms, and parts of North China fell under non-Chinese rule. During the following centuries of disunion, the Confucian tradition was somewhat eclipsed by Daoist sectarian traditions and by the rise of Buddhism. Beginning in the Song dynasty (960-1279), a Confucian revitalization movement gathered momentum. Meditation, visualization, and other interior spiritual techniques inspired by Buddhism and Daoism developed, and traditional Confucian ethical concerns were now linked formally to a notion of the cosmos as inherently inclined toward moral good. Mencius’s view that human nature is essentially good was reaffirmed by the great neo-Confucian Zhu Xi (1130-1200), who promoted the works of Mencius, together with the Analects, the Great Learning, and the Doctrine of the Mean, as the basic course of education in Confucian ideology. It was Zhu Xi’s editions of these and other classical Confucian texts that informed the imperial Chinese civil service examinations.
Zhu Xi further contributed to the development of Confucian practice through his preparation of detailed family regulations. In addition to providing minute descriptions of ritual preparations, he admonished sons and their wives to acquire medical knowledge adequate to care for their parents (and parents-in-law). Not only should they know how to prepare certain medicines, they also should be able to select reputable physicians—practitioners who, in Zhu Xi’s day, were viewed as little different from barbers and masseurs. Filial duty also entailed assumption of the primary burden of care. The sense that elder care is the responsibility of the family remains widely and deeply ingrained in Confucian societies. In China, however, with the decline of the extended family as a result of the one-child policy, reports of abandoned seniors have become increasingly common, leading the state in 2013 to institute new “filial piety laws” requiring mandatory visitation of elderly family members.
New Confucianism
After the fall of the Qing dynasty in 1911, Confucianism was widely derided by Chinese intellectuals as a remnant of a feudal past that hindered China’s rightful advancement into the modern world. Much of the blame for women’s oppression, for example, was allocated to “Confucius and sons,” and study of the canon was replaced by scientific and technical training. Nonetheless some scholars believed that Confucianism, freed from its feudal origins and centuries of accreted (and erroneous) practice, could be rehabilitated. An international revitalization movement now known as New Confucianism arose in the 1920s at Peking University under the intellectual leadership of Xiong Shili and continued to develop through the 1940s at New Asia College in Hong Kong under Tang Junyi. During the 1960s the movement gained added momentum by the efforts of Mou Zongsan and Xu Fuguan at Tunghai University in Taiwan. These New Confucians asserted that the tradition holds spiritual resources sufficient to meet the challenges of industrialization, urbanization, and bureaucratization and to combat the depersonalization of the modern world.
Contemporary New Confucians draw inspiration from Lee Sangeun (South Korea), Okada Takehiko (Japan), and Tu Weiming (Harvard and Beijing Universities). Following his teacher Mou Zongsan, Tu Weiming has championed Confucianism as a world religious tradition, its ideals and practices open beyond ethnic heritage borders to anyone who shares its anthropocosmic vision. And there are many who do. Robert C. Neville, author of Boston Confucianism (2000), is a prominent example of those persons, often philosophers, who claim a dual religious orientation and who write persuasively on the significance of Confucian tradition for the West.
Bioethical Issues
The question of whether the four ethical principles of biomedical practice (autonomy, nonmaleficence, beneficence, and justice) articulated in the West over the past half century are universal or culture specific presently dominates discussion of bioethical and biomedical issues in Confucian-influenced societies. Western emphases on individualism are contrasted with Confucian familialism: post-Enlightenment notions of autonomy, in which every person has the right to make decisions regarding his or her own body, challenge the extent and supremacy of family determination, in which decisions are made on the basis of benefit to the ancestral past, the present family, and future generations.
Mencius underscored the filial necessity of producing an heir to ensure the care of elderly parents and the maintenance of ancestral veneration. He said, “There are three ways to be unfilial, and the greatest of these is to be without posterity” (Mencius 4A26). In the premodern world posterity meant a son or, preferably, sons. The resultant pressures on a woman were great. She was to bear children early and often; to continue bearing children until at least one son was born; and in cases where she failed in this requirement or seemed likely to do so, to accept divorce or the introduction of concubines into the household.
In the early twenty-first century the imperative to produce a son remains strong and has had a profound impact on the growth of certain reproductive technologies. The desire for male offspring coupled with restrictive population control measures in China and with trends toward smaller nuclear families in the industrialized nations of Japan, Taiwan, South Korea, and Singapore has led to increased use of sonograms for fetal sex determination, often followed by elective abortion if the fetus is female. Of course to describe abortion as elective in this context is to gloss over the many pressures—economic, spousal and familial, societal—that may accompany the decision; use of the term here indicates only that the procedure is not medically necessary.
Abortion itself is condemned in the Confucian tradition as a mutilation of familial flesh. Buddhist notions of karma and the Buddhist prohibition against the taking of life compound the sense that a fetus should be protected. However, there is widespread ambiguity in the popular imagination about the ontological status of the fetus, as noted in studies of fetus-ghost appeasement rituals in Japan and Taiwan. Most people believe the fetus to have a soul at conception, yet there is also the belief that this soul is not solidly anchored, meaning that it is extremely susceptible to fright—and flight—during gestation and into the first 100 days of infancy. A soul that escapes its body in this way will likely make its way to another body, but the specter of a free-floating vengeful spirit has fueled a lucrative fetal-ghost appeasement industry.
It must also be noted that nominally Confucian cultures have long embraced a pragmatic ethical relativism, sometimes attributed to Daoism, that seeks to maximize personal and familial benefit while avoiding inauspicious residual effects. In late twentieth-century China, an alternative to abortion and female infanticide emerged. After birth unwanted infant females can be left anonymously at local orphanages or social welfare offices, or else they can be sold quickly to baby brokers who then deliver them to state facilities. In this way the state has found itself with a seemingly inexhaustible supply of a highly desirable commodity: infant girls for the international adoption market.
In some areas the male-female sex ratio of recorded live births is severely and increasingly skewed in favor of males. In South Korea the use of ultrasound screening to determine fetal sex is illegal but widely practiced. In 2008 the overall male-female ratio of recorded births in China rose to 120.56:100, whereas the expected average would be 105:100, and the largely rural provinces of Anhui, Jiangxi, and Shaanxi reported ratios of 130:100 (Xinhua News Agency 2010). Government campaigns to combat sex preference may be responsible for the later slight declines registered nationally to 117.78:100 in 2011 (Xinhua News Agency 2012).
It is impossible to know with certainty the exact numbers of the “missing girls” who were aborted or were victims of infanticide or who were born and kept by their families but whose births were not recorded on official rosters. What is known is that decades of increasingly unbalanced male-female ratios have given rise to reported kidnappings, mail-order marriages of children, and wholesale trafficking in women.
Ownership of the Body
Confucian tradition holds that one’s body is not truly one’s own; rather, it is intended for the preservation of the familial line and the ritual veneration of one’s parents and ancestors. In a particularly gendered illustration of this notion, the historical records contain many examples of filial daughters and daughters-in-law who, charged with the care and feeding of parents and parents-in-law, cut flesh from their own arms or legs to make nourishing broth in times of war or famine. In other circumstances, however, to harm or mutilate one’s body might render it insufficient to its purpose of care for preceding generations. To a Confucian therefore, preserving the integrity of the body is of great importance. This holds true even after death, for although the deceased becomes an ancestor him-or herself, he or she remains at the service of still earlier generations.
Here, too, the complexity of Confucian interaction with other traditions becomes apparent. Internal organs are valued only for their functions, and thus the donation of a sample of bone marrow or of a single kidney would seem permissible. However, the general Confucian sense of the body remaining intact to serve one’s family is compounded by the popular Buddhist notion that a body must be complete to move through its karmic destiny. For many people in Confucian cultures therefore, the combination of these beliefs has precluded acceptance of organ donation and transplantation up until quite recently—and often only under the influence of socially engaged Buddhist groups. One such group is the Taiwan-based Tzu Chi Buddhist Compassion Foundation, a lay organization that claims 5 million members worldwide. Founded in rural Taiwan in 1966 by the dharma master Cheng Yen, a self-ordained nun, the Tzu Chi Foundation exhorts women to fulfill their traditional Confucian role of dutiful wife and mother even as it promotes women’s volunteer efforts outside the home, particularly in medical care and disaster relief. In 1994 Tzu Chi established a bone marrow registry that in the early twenty-first century is the third largest in the world. Tzu Chi encourages organ and tissue donation (and even body donation for the training of medical students) as examples of Buddhist compassion. Challenging traditional Confucian-Buddhist attitudes toward the body, Cheng Yen emphasizes the interconnectedness of all beings and the importance of practicing compassion to save lives.
In China the problem of traditional Filial/familial attitudes toward the body are complicated by the influence of the free-market economy. China’s rapid economic development and push for urbanization have brought huge population dislocations that disrupt traditional familial structures. With the commodification of daily life now extended to include the human body and its parts, organ trafficking is a growing concern. In 2007 the central government’s State Council promulgated the Regulation on Organ Transplantation banning trade in human organs and underscoring that a citizen’s right to donate organs (or to refuse to do so) should be protected. However, questions remain concerning the coercion of prior consent from condemned prisoners and conditions of gender bias, in which patriarchal families pressure women to be donors for male members.
In 1985 China launched market-oriented health care sector reform. Although this has resulted in a greatly increased quality of health care, the extreme income disparity of the late twentieth and early twenty-first centuries leaves many people without access or dependent on extended family finances. In the latter case individual autonomy in treatment options—as well as bioethical principles of beneficence and nonmaleficence in patient care—can be threatened by paternalistic determinations of cost-benefit ratios to the family unit as a whole.
Confucian cultural models of familialism are not always in conflict with general bioethical principles, but the debate is vigorous. In 1988 the first Chinese bioethical association was launched. In 2005 the first International Conference on Healthcare Services, Markets, and the Confucian Moral Tradition was held, and in 2008 Asian Bioethics Review initiated publication. Scholarship seeking to harmonize Western or international guidelines with what are sometimes called “Asian” cultural values focuses on the “principlism-Confucianism debate.” The self-identifying Confucian bioethicist Fan Ruiping argues that the cultivation of virtues and “reflective equilibrium” at the heart of Confucian practice is sufficient and equal to the task of addressing bioethical issues. This claim is challenged by Leonardo D. de Castro (2008, 2012), who finds the description of “virtues” unequal to the provision of “principles” in offering definitive guidance for decision making. Moves to reconcile these views are offered by Michael Cheng-tek Tai and Chung Seng Lin (2001), who promote the development of an “Asian” bioethics that is culturally relevant and that may require the reinterpretation of Western principles. Another view is offered by Zhai Xiaomei (2011). In classic Confucian style the appeal is to Confucius’s own words in the Analects to promote a vision of decision making that draws on universal values (the four principles) in harmony with native resources: “in harmony but not identical” or “in harmony but diversified” (ho er bn tong., Analects 13.23). The debate is far from concluded.
For people in “cultural China” (that is, China and its special administrative regions, Taiwan, Singapore, and diasporic communities worldwide), Korea, Japan, and Vietnam, Confucianism is perhaps best understood as providing a substratum of belief, complementing or complicating other beliefs and values, whether sectarian or secular. Although scholars can debate Confucian responses to any issue, a single Confucian judgment is probably impossible to construct. In the syncretic and diasporic world of Confucian cultures, a Korean Christian Confucian may hold one opinion, a Japanese Buddhist Confucian another, and a “Boston Confucian” yet another view altogether.