This paper by Dr. He Huaihong, Peking University philosophy professor, was presented at the Ethics and Public Policy Center on January 22, 2003, to launch the discussion at the "Chinese Bioethics?" conference.

This lecture is to give a brief account about some affairs and relevant disputes of bioethics (or mainly medical ethics) in China. But what has to be explained at first is that I am not an expert in this field. My main concerns have been confined in basic theories and history of ethics in China, especially theories on justice. I translated A Theory of Justice by John Rawls and Anarchy, State and Utopia by Robert Nozick (both authors regrettably passed away last year), studied the transformation of social structure in ancient China from a hereditary system to a selection system, and tried to put forward and develop a universal and minimalist ethics for the sake of situations in contemporary China. And I am looking forward to exchanging opinions about them. I do care about medical ethics as well, but my experience of it is mostly as a patient instead of as a researcher, so I just introduce other scholars’ studies except the part of concerning Chinese traditional thoughts. Likewise, this lecture is more to present questions than to give conclusions.

"Birth, aging, illness and death" is a Chinese saying, which sums up the four major worries in life besides famine and war. Generally famine and war are unusual, and in that case often only a minority are directly involved in; while the four are the routine of life, they are common to almost everybody, especially in the case of birth and death. Ancient Confucians highly valued good birth and good death. For example, a great Confucianist Xun Zi (300-237 BC) said:

"Birth is the beginning of man, death his end. When both beginning and end are good, man’s way is complete." [Hsun Tzu, p. 96., translated by Burton Watson, Columbia University Press, 1963.]

This lecture is to discuss the following three issues:

1. legislation and controversies about eugenics;
2. two cases of euthanasia along with corresponding analyses;

3. comments correlated with traditional thoughts of China.

1.  EUGENICS

A. Legislation

China passed the Maternal and Infant Health Care Law in 1994. The following are key excerpts from the official translation legislation which came into effect in 1995.

Article 8: The pre-marital physical check-up shall include the examination of the following diseases: (i) genetic diseases of a serious nature; (ii) target infectious diseases; and (iii) relevant mental disease.

Article 10: Physicians shall, after performing the pre-marital physical check-up, explain and give medical advice to both the male and the female who have been diagnosed with certain genetic disease of a serious nature which is considered to be inappropriate for child-bearing from a medical point of view; the two may be married only if both sides agree to take long-term contraceptive measures or to take ligation operation for sterility.

Article 16: If a physician detects or suspects that a married couple in their child-bearing age suffer from genetic disease of a serious nature, the physician shall give medical advice to the couple, and the couple in their child-bearing age shall take measures in accordance with the physician’s medical advice.

Article 18: The physician shall explain to the married couple and give them medical advice for a termination of pregnancy if one of the following cases is detected in the prenatal diagnosis: (i) the foetus is suffering from genetic disease of a serious nature; (ii) the foetus is with defect of a serious nature; and (iii) continued pregnancy may threaten the life and safety of the pregnant woman or seriously impair her health.

In these articles, "genetic diseases of a serious nature" refers to diseases that are caused congenitally by genetic factors, that may totally or partially deprive the victim of the ability to live independently, that are highly possible to recur in generations to come, and that are considered medically inappropriate for reproduction; "relevant mental diseases" refers to schizophrenia, manic-depressive psychosis, and other mental diseases of a serious nature.

B. Criticism

According to Mao Xin, a geneticist formerly of the West China University of Medical Sciences and now at the Institute of Cancer Research in Britain, the international opinions on the Chinese law vary. Some Western geneticists have said that "in a country where millions of female children vanish, and many children with developmental abnormalities are left to die, the law might represent an improvement".

Some western geneticists have fiercely criticized the law as an "abuse of genetics" and a "violation of human rights". During the 18th International Congress of Genetics held in Beijing in 1998, the issue of the China's new law was discussed. A statement produced at this discussion and released at the congress closing ceremony, which without mentioning China by name said that "new genetic technology should be used . . . not as a tool of public policy or coercion", forced many interested delegates to focus on the issue. Several scientists did not attend the conference out of protest.

Frank Dikötter, director of Contemporary China Institute, University of London, said that "the present eugenic legislation does not reflect this consensus-making process; it imposes decisions." It will been used to suppress rather than assist vulnerable people.It reappeared as an intrinsic component of the one-child policy of 1978.

There is opposition to the law in China too, from some geneticists who trained in Western countries. For example, they oppose some radical measures such as "sterilization of people with IQ less than 60" and the use of term "eugenics" in the early draft of the law. Some Chinese geneticists and bioethicists have criticized some articles of the law. Their suggestions include more explicit recognition of the principle of informed consent.

C. Explanations

Qiu Renzong, Bioethics programme director of Chinese Academy of Social Sciences, admit that the Law has attracted considerable criticism in the Western media and scientific circles. he thought some of the criticism is valid but some is based on misunderstandings caused by linguistic or cultural barriers. Much of the confusion revolves around the word "yousheng", which repeatedly occurs in the legal text. A tricky word with dual meanings, it is commonly used to mean "healthy births" in association with child-rearing. However, "yousheng" can also be used to describe eugenic programmes such as that practised by the Nazis. Unfortunately, English translations of the law seem to convey only latter meaning.

Is the Maternal and Infant Health Law eugenic? Qiu said that for a policy to be eugenic it must first reject individual consent and second, be based on racism. Neither of these conditions applies to China’s law. While doctors may advise two individuals at risk of passing on hereditary disease to refrain from marrying or to undergo sterilization, the ultimate decision is left to these adults. It is also crucial to recognize that the law is not motivated by racism but by a desire to reduce birth defects. Indeed, there is no racist tradition in China.

Besides, There are now more than 50 million handicapped people, mostly living in poverty, and it is unreasonable to expect any major improvements in the treatment of handicapped children and their mothers in the near future. In this context, many feel that these children and their mothers would be better off if the handicapped had never been born.

Qiu said: "The principle is informed consent (like in Western countries)." But in authoritarian China, there was no history of proper information or voluntary consent, said Mao Xin. But he also thought that the term "eugenics" has many meanings. Eugenics can be voluntary or coerced, government sponsored or individual, a "science" or a social policy, based on the welfare of individuals or on the welfare of society or a nation. The word "eugenics," which currently is used more widely in China than in the West, when directly translated into Chinese, is "yousheng" and "youyu," which mean "well bear" and "well rear." The view most widely held by Chinese geneticists is that eugenics implies processes designed to ensure that children who are born are "normal.", as far as possible.

Dr. Wang Yanguang called for a new definition of eugenics. She thought that the Chinese word "Yousheng" is same as the Greek word eugenics meaning "good in birth", also it is belong to the Galton's eugenics' core doctrine of improving the stock of humankind by application of the science of human heredity. In this sense, the Chinese word "Yousheng" can be translated as eugenic. But it is different from the US and the German "eugenics" in history.

In her opinion, we should recover the core doctrine of eugenics - good in birth and preventing the defect of the birth voluntarily. We can focus our attention on negative eugenics. Genetic medicine which has found some defective genes or some certain proof of what causes inherited diseases has made it possible. We can do something for positive eugenics, but the eugenics programs could limit its focus to those human characters on whose desirability there is universal or widespread agreement . Anyway, few of us are entirely free of the eugenic thinking" good in birth" in some aspect of our daily lives. A parent may decide to delay having a child until he or she financially and emotionally ready to be a good provider and parent. Most modern governments hope that their people will be energetic, ingenious and enterprising. But the eugenic thinking and practice should balance the interest of all sides.

2.  BAD LIVING OR GOOD DEATH?

A. The first euthanasia court case in China

On 23 June, 1986, Xia Suwen, a 59 year old female, was taken to Han Zhong hospital (Shan Xi province) for infectious diseases, because she suffered from ascites, cirrhosis of the liver. Even though her condition turned a little better after several days’ treatment, it became worse on 27 June and she kept on crying that, "It's so painful that I don't want to live". After Wang MingCheng, one of her sons, learnt that his mother's condition was hopeless on 28 June, he asked Dr. Pu Liansheng, the physician in charge, to inject some medication to let his mother die without pain, but Dr. Pu refused at first. After Wang implored Dr. Pu several times, Dr. Pu was persuaded to let trainee nurse inject 100 ml compound at 9 a.m. on 28 June, before which Wang signed a formal letter saying "Family member asks for euthanasia, Son: Wang MingCheng". Before Dr. Pu went off he ordered the night shift doctor to give a further injection if Xia didn't die. At 3am Xia was injected with a further 75ml of wintermin compound and died at 5am on 29 June, 1986.

Other children of Xia Suwen sued Dr. Pu for killing their mother, so Dr. Pu and Wang MingCheng were taken into custody on 20 Sept and 30 Sept, 1986, respectively. Pu and Wang were released on bail to await trial on 20 Dec and 24 Dec 1986. On 17 Aug and 29 Aug, 1987, Pu and Wang were seized again by the People's Procuratorate of Han Zhong, and the People's Court decided to release them on bail again on 23 September.

On 15 March, 1990, nearly four years after the incident, the People's Court of Han Zhong held the court. Following the statement from the public prosecutor that the use of Wintermin compound, which should normally be used carefully or avoided, violated the Criminal law Rule 132 of the people's Republic of China, and they committed the offense of intentional homicide, there was a loud roar of discontent from the public gallery. The court continued on 17 March, with the expert conclusion from the Malpractice Appraisal Committee of Shan Xi Province, of 10 July, 1989, "Wintermin compound was not the direct cause of Xia's death, but it did deepen the coma of Xia which promoted death. The debate began in court, and the defense lawyer Zhang Zanning made a successful justification for the defendants. On 17 May, 1991, the first judgment was declared, "Even though the wintermin compound hastened Xia's death the dose was not excessive, and circumstances were not severe enough to constitute criminality", and they were both found "not guilty". The final judgment by the Intermediate People's Court of Han Zhong Prefecture rejected the appeal of the plaintiff (the People's procuratorate of Han Zhong) and upheld the first judgment.

Dr. Cong Yali analyzed the case. She thought that there are two main characteristis of euthanasia in China: 1) The status of the family is more important than the patient's right. In China consent for an operation must be agreed and signed by a family member, not the patient himself. 2) Filial piety is still regarded as the basic moral standard. Considering 80% of Chinese are poor peasants, who cannot afford xpensive medical technology use by a hospital, children may prefer to take their parents home and let them die naturally, rather than injecting them with medication which may hasten death.

Nine uraemia patients from Xi'an city, who are tired of unbearable suffering and not willing to burden their families any more, after long consideration jointly wrote to local media asking for euthanasia, or mercy killings.

Some of them received an interview on April 4. 2001. Due to kidney failure they have to depend on naemodialysis for life, and every time they suffer a lot. This life is better dead than alive. Mr Wang told the reporter: "For me, every day is as long and miserable". The 68-year-old Cheng Yunsheng said: "I have to go through three times naemodialysis every two weeks, and I'm too weak to move, feeling like staying in a jail all day". Apart from the pain, the heavy burden on their families is another reason for their lodging the request. Li Xinhua, a teacher from Shan Xi Economic and Trade College, tells that the minimum treatment fee for every month was over 4400 yuan, a heavy load on his family despite helping hands from his working unit, relatives and friends. One of his sons had to quit college and went to find a job in Shenzhen. Now both his two sons are near thirty but they have no money to get married.

A survey by the Chinese Academy of Medical Science found 95% of medical workers approve of euthanasia. But China has so far no legalized euthanasia, that is, no institutions and persons are permitted by law to conduct euthanasia, otherwise legal punishment may follow. In practice euthanasia is often done in secret. A question in dispute is whether and when euthanasia should be legalized in China.

In these cases, the main reasons for euthanasia include corporeal sufferings of the patient and concern of heavy burdens to the family, which may be both economic and psychological. The Chinese people are quite resistant to tortures as they say "a living ass is better than a dead lion", but when the distress turns out to be no longer endurable, death would become a natural choice, while it would be a factitious interference to prolong life by some special or costly medical treatment. "Good death" seems to be a paradox, for death is never desirable by itself, but it could be preferable if life was worsened enough.

3.  COMMENTS

(1) Traditionally the Chinese believe that "the great characteristic of Heaven and Earth (Nature) is to produce forever", the lives of living beings go on without end. And their view of life imitates that of nature. Therefore, continuous reproduction ("shengsheng") is not only the virtue of nature, but the virtue of human. Generally speaking, the view of life is universal and fundamental, tending to harmony, giving more attention to basic demands such as avoiding harm of life and ensuring necessities of life, while somewhat ignoring full development and enjoyment of life that may lead to heated competition and rivalry.

(2) Accordingly, the Chinese believe that while life is valuable, it is not to be clung to. It is a natural affair, and death is regarded as "going home", as returning back to where life comes from, just as fallen leaves settle on their roots and fallen flowers return to the soil. This is the great circulation of the universe. Chuang Tzu, A famous thinker of Daoism, said: "In the limbo of existence and non-existence, there was transformation and the material force was evolved. The material force was transformed to be form, form was transformed to become life, and now birth has transformed to become death. This is like the rotation of the four seasons, spring, summer, fall, and winter."[A Source in Chinese Philsophy, translated and compiled by Wing-tsit Chan, Princeton University Press, p. 209, 1969.]

Therefore, negative euthanasia (leaving to death) is relatively more liable to be accepted by Chinese than positive euthanasia (helping death) is. In fact, the latter tends to be rejected in most cases.

(3) Meanwhile, ordinary real life, especially family life, is highly valued in China. Confucian ideas of filial duty, such as "among the three major offenses against filial piety, not to produce an heir is the gravest" and "one should bring honor to his family name", are still active in today’s Chinese society. Then it is understandable that people under the "one-child" policy generally expect the only child be conceived, born and reared with greatest care.

(4) China has long been confronted with the great pressure of population surplus. Therefore, it has to pay more attention to present people, trying to control the increase in quantity, along with the hope of improving its population quality. Thus the will of government coincides with that of the family and is likely to support the idea of eugenic.

(5) Traditionally the Chinese make much of interpersonal relations. they approve interdependence among people other than independent selection. Therefore, it is usually obligations to others (including one’s relatives) other than the idea of rights that makes up their main consideration of option. Furthermore, respect for life is more likely out of the plain idea that life is precious than due to the belief that life is divine.

Finally, let us end with "The Western Inscription" by Chang Tsai, a Confucianist of Song Dynasty, which typically expresses a traditional view of life in China:

[A Source in Chinese Philsophy, translated and compiled by Wing-tsit Chan, Princeton University Press, pp497-498, 1972.]