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8.4. Teaching Medical Ethics in China. Cultural, Social and Ethical Issues

- Ole Doering, Ph.D.
Zentrum Medizinische Ethik
Ruhr Universitaet
Postfach 102148
D-44780, Bochum, GERMANY
Email: ole.doering@ruhr-uni-bochum.de

1 Introduction

In medical ethics, we are used to focus on theoretical problems, such as moral principles, the moral status of unborn or seriously impaired human beings, or ethical regulations and institutions. These are important issues, indeed. However, when we consider medical ethics in practice, in particular the qualification required by medical professionals in their work, this level of thinking is sometimes regarded as impractical. It can be argued that abstract discussion is not immediately relevant for dealing with the practical issues at stake, but that there is an urgent need to improve the situation at hand.

What makes ethics important in medicine is, from a practical point of view, not so much that it informs us about a moral truth or rule, but prepares us for right action in difficult situations. It does not contradict the bases of sound scholarship. The focus on "right action" is relevant for decision-making. Medical professionals need to learn how to live up to their responsibility, to refine their human sense of empathy and prudence, and to achieve a balanced judgement when confronted with a diversity of moral cultures. A genuine interest in "doing the right thing" serves as a constant reminder of each one's moral inspiration. It stimulates and encourages students to develop the relevant capacities to become "good" in doing their job right, forming a moral character, which corresponds with the moral intuitions and the professional calling that make a doctor choose his profession in the first place.

A systematic program designed to shape such a development, according to a non-cynical approach, is education. Education in medical ethics should be an open and life-long process, throughout which the student internalizes the results of her or his efforts in combining reflection of moral sense, learning - and guidance by authorities, to create a sustained process of maturing through moral experience.

The methods and contents in teaching medical ethics obviously need to accommodate the respective cultural, social and personal situation of the respective individual. A Chinese medical student brings in her or his unique set of moral preoccupations, experiences, narratives of social life and moral concepts, which can be expected to be different from those of a colleague from Germany or Canada. And the medical student from Beijing will most likely be different from a classmate in Chengdu and other places in China, as he might detect shared views and interests with a peer in Hamburg.

There is a heterogeneous situation to start with, when we discuss, who it is that begins to study medical ethics. However, notwithstanding their individual motivations and beliefs, Chinese medical students and their teachers in ethics classes encounter a similar cluster of challenges, which result from their country's enormous social, scientific and educational systems' transformation.

2 Approaching medical ethics education: an example

What medical ethics education is about?

In Europe and America, quite a few institutions offer national and international programmes in medical ethics education. The main motivation for such an engagement is to train the new academic and bureaucratic experts, who are needed to cater for the growing demands for technical aspects of knowledge in bioethics. This includes lawyers, specialists in patenting issues, facilitators of interests (lobbyists) and public relations, especially in the related industrial businesses and administrations. China and other developing nations also increasingly demand for such experts. However, it should be noted that their kind of training is qualified by an agenda of bio-policy, which is more narrowed than a humanitarian approach to ethics, and tends to be instrumental for certain given interests.

All these approaches I would like to put aside for the purpose of this paper. Instead, I would like to define medical ethics education more fundamentally, as a way to improve the capacities of medical professionals to "do the right thing", according to the traditional concept of medicine as an "art of humaneness". This means that medicine is addressed here as a professional and scientific approach to help others in becoming or remaining to be healthy. In this sense, medicine has an intrinsic moral drive, making it distinct from ventures that provide mere technical biomedical services or procedural skills in handling legal or political controversies. Evidently, in real life, the situation of medicine is composed of elements from both sides.

In August 2002, I organized in co-operation with professor Du Zhizheng and conducted a training course in teaching medical ethics for professors from all over China, in Dalian (Liaoning province). The course was sponsored by the Heinrich-Boell Foundation (Berlin). We attempted to implement an adaptable model for teaching medical ethics, with a special interest in international, cross-cultural methodological and pedagogic issues. Why did we begin this project?

Medical ethics education in China: basic facts and recent development

China's system of medical education is currently changing. Medical ethics has been taught as a required course until now, with a strong tendency to emphasize correct ideological thinking, instructing students in being moral models of humane behaviour, and to avoid conflicts. It is estimated that, currently, about 160 scholars from different academic backgrounds are engaged in medical ethics education all over China. Classes are huge in size (up to 300 students). Professors hardly receive adequate training in ethics, nor does the curriculum include much of the related literature or updated theories and concepts in medical ethics, neither as compared with the respective international standards, nor as incorporating relevant interdisciplinary insight, e.g. from the social sciences, humanities and pedagogy. The professors' salary seems to be insufficient to compensate the high level of responsibility medical ethics teachers' bear, with their impact on moulding the new generation of medical professionals, and their readiness to understand ethics in medicine. In general, the situation was believed to be inadequate at all levels, leading to frustration on the teachers' side, annoyance among students and a sense of ethics as being nothing but a pointless waste of time.

The real development in medicine and on the health sector has made this state unbearable, even for those experts with no special interest in ethics. Real life is moving on, specialization and economization take place, technology plays a greater role, new legal and technical standards are implemented, and, more recently, an increasing awareness and readiness among patients and human subjects to claim their rights, has changed the cultural and socio-economic environment dramatically. The level of medical services available is advancing, offering state of the art facilities to a privileged few, whereas the vast majority among the population often has difficulties to access the basics.

A modern spirit encourages creativity, individual decision making, responsibility, accountability and competitiveness among the academic elite in particular. The teachers' role is in flux, gradually changing from being bullied by a "curriculum by command", towards a curriculum by the faculty's design and individual teachers' responsibility. The ongoing restructuring of the medical sector in China induces an urge to adjust the institutional and conceptual framework for medical ethics education, so as to enable students to cope with the difficulties in their future jobs.

Besides many other things, ethics is needed to remind medicine of a larger perspective of "doing the right thing", qualified by the aspiration to contribute to a good life, from the humane medical view. Modern health professionals are expected to handle different situations appropriately, exercising their intellectual creativity, and refining their sense of empathy beyond the scope of paternalistic sympathy. Obviously, the capacities of teaching methods that "fill in" students with factual knowledge and ethical theories are limited in reaching such a goal. Teachers themselves should understand the peculiar situation of learning to become a doctor who tries to do the right thing first, before they teach students. This can be achieved by using interactive, multiple and practice oriented methods that would allow much freedom in learning by trial and error.

A training course

This course was held in Dalian, August 7-13, 2002. 30 participants form 27 medical universities and medical schools in 18 provinces (some as remote as Xinjiang, Sichuan and Anhui) attended. A team of 9 ethicists, from the US, Germany, New Zealand and China conducted two sessions a day, each scheduled for three hours, in the morning and in the afternoon. The focus was on interactive engagement concerning crucial problems in medical ethics. We introduced ethical and pedagogic theories and methods, assessing and attempting to solve given individual cases; frequently, the class was split into 5-6 sub-groups who were asked to discuss either a certain case or a given approach, and to explain, defend and criticize their respective conclusions. This style was interchanged with more conventional forms of lectures and open discussions.

Participants were invited to digest and compare different individual forms of teaching, each of which was free to perform within a given time frame of three hours, thereby experiencing the merits of a diversity of "teaching cultures", as well as learning to appreciate the particular perspective of the student. The class was encouraged to envisage the teacher as a human being and a partner in a process of problem solving, rather than as an authority beyond affectedness, thus modelling the situation of a medical doctor dealing with a patient on the basis of trust and respect.

Throughout this course, participants showed a high level of interest, motivation and dedication, with a determined willingness to improve and in some cases an already existing very high level of scholarship and reflection. The topics chosen include the following.

"Main Theories in Medical Ethics and How Theory Matters" (Qiu Renzong)
"How to use Case Studies" (Jim Dwyer)
"Pedagogic Approach to Medical Ethics. Principles, Theories, Practice" (Ann Boyd)
"The Physician-Patient-Relationship: Autonomy and Informed Consent" (Gerald Neitzke)
"The Ethical Disputes about Human Embryonic Stem Cell Research." (Li Benfu)
"Social Darwinism and Social Engineering: International and Chinese Perspectives" (Nie Jingbao)
"Medicine and Society: Professional Responsibility in Clinical Research in China" (Zhai Xiaomei)
"Assessment of the 'Human Drama'. Methods and problems" (Ann Boyd)
"Teaching Aims and Teaching Methods in Medical Ethics" (Gerald Neitzke)
"Cultural Issues and Understanding in Medical Ethics" (Ole Doering)
"Assessing Deathbed Care and Anlesi (Euthanasia)" (Du Zhizheng)
"Justice and Solidarity in Medical Ethics: allocation of organs and other issues" (Jim Dwyer)
"How to Teach Medical Ethics. Useful Methods and Theories Revisited" (Nie Jingbao)
"If we had another chance to organize such a course: Where should it be? What should be included? How should it be done?" (Group work and open plenary debate)

In addition, a classical case in medical ethics from the US (The "Dax Case") was shown and discussed over two evenings. Another evening was spent on discussing cases introduced from Germany (Neitzke), with the task to comment and compare them with the different situations in China. On the last evening the question was pondered, how Chinese participants would be able to benefit from this (or another kind of) course in medical ethics education, considering the particular conditions in their respective work unit.

3 General observations for cross-cultural medical ethics

The emphasis on methods and a "design under construction" was deliberately chosen because the organizers did not want to implement any given theory or cultural perspective to our colleagues in China, nor did we mean to imply that any such perspective or a given design could serve as a model. The participants were requested to actively engage in a critical and constructive process of learning, which included the lecturers. This helped to appreciate the particular situation of their students who they might hope are going to co-operate in class later likewise. It seemed very important to show how much depends, not on theories, but on the personal engagement of the humans who act as teachers and students, or, as doctors and patients, respectively. Learning to take responsibility and being encouraged to use one's practical reason creatively in ethics, can not be simply taken from studying books or memorizing what the teacher says. They need to be embedded in real life's experience. The teacher is requested to mould them according to his apperception, and to bring ethics to life.

This is not to downgrade the importance of theories, but to put theory into a proper perspective. Theories were introduced to the course in the sense that, although they would not represent "true ways" or dogmas, a few theories in medical ethics, such as deontology, utilitarianism, or a theory of justice, etc., could be assessed as useful tools with limited application. This notwithstanding, theories can not impose any particular vision of moral truth upon medical students and teachers, and they have to be empirically sound, duly informed and practical. In this light, the deliberate bias in this courses approach can be summarized in "3 P's": Medical ethics must be person centred, patient centred and problem centred.

Moreover, in their response, some participants demanded "3 times more": spending more time, meeting more often and learning more theory while maintaining the focus on practice. Besides, a lamentable lack of suitable books and other materials in teaching medical ethics was confirmed.

The problems identified in the case discussions revealed that the topics did not differ as much between China and other nations as many had expected. Basic moral intuitions did not seem to be controversial. For example, there was no controversy regarding the doctor's primarily concern with the wellbeing of the individual patient. However, the special ethical, moral, legal and social considerations, together with the ensuing measures, were identified differently, between foreigners and Chinese, and notably among the group of Chinese contributors. Some called for greater respect for the individuals' decision under all circumstances, others opted for some professional leeway in the name of medical paternalism, others again argued, that issues of social justice and the patient's responsibility for others, (such as family members or society), should be acknowledged. This inconsistent landscape of opinions seems to represent a plurality of "moral cultures" and ethical approaches inside China, as well as in medical ethics in general.

Some fundamental considerations

In designing this experimental training course, some fundamental considerations puzzled me. First of all, can medical ethics be taught at all? If we do not acknowledge the natural capability of humans to learn morals and to will to do better, we can expect no motivation to try and teach ethics. Our moral sense suggests that health and life are dignified, not because they are useful but because they are meaningful. However, being in the possession of the capability and moral sense implies that our practical judgement needs to be corrected and readjusted by the experience of real life. If we acknowledge this, we come to believe that ethics can be taught.

Moral preaching, as a traditional method of teaching ethics, has three strong points. It is convenient, makes clear statements to be carried home and it defines a clear structure of authorities, hierarchies, norms, and it establishes power. So, what is the problem with moral preaching? What is the problem with dominance of power, ideology and indoctrination? These approaches can function only as long as they are embedded in favourable social, political and economic conditions. As soon as the teacher's formal authority is used as an instrument to hide incompetence, this authority faces the danger of embarrassment and ridicules herself. The emperor stands without clothes and no one is afraid to point at his nakedness. Besides the hubris on the side of the "preachers" and their gross misconception of human nature, reason and learning, their major flaw is that they reduce the interactive process of education to a farce of mere passive reception (zhuru), with no expected effect on the teacher. The strict sharing of roles between pupil and teacher (shi chuan sheng shou) is a reminiscence of the past, when societies were based on a different kind of economy. In our days, at the beginning of the high-tech and information society, individual creativity, engagement and civil responsibility are the most wanted abilities. They virtually contradict blind obeying and mimicking. The logical consequence, on the other hand, is that it will not be as easy as it might have been in the past to determine, manipulate and utilize the people according to the social engineering plans of any authority. Still, obeying a superior's orders plays a certain role in the realm of prudence, but it can not satisfy the demands of ethics.

The Yixue yu zhexue journal ("Medicine and Philosophy") has indicated that only a small segment of medical students express an interest in ethical issues. Only about 19% of the students, who had been interviewed are actually interested in helping people. At stake is not only an ethically well reflected, reasonable medical practice, but also, how to gain more support from physicians and society? 19% is less than one in five of medical students. This is hardly a satisfying point of departure. This is particularly disturbing if we bear in mind that medical freshmen at the start of their professional training are commonly expected to be more idealistic and determined to help and heal for its own merits. Without a functioning ethics education on a high level, the future situation of medical practice can not improve, in spite of advanced bio-sciences and heavy investment in the health services. The toll taken by frustration and routine is due later in the course of study and career. It would amount to cultural suicide if a society would invest greater efforts in creating a technical infrastructure according to the state of the art in biomedicine than to encourage and nurture humanity, including ethics. A fundamentally technocratic attitude towards medicine from the very beginning seems to indicate an unhealthy situation in society, mirrored by the absence of real ethics teaching in medical education.

Thus, in the light of the changing social role of medicine, medical ethics education can be regarded as part of the general task to educating the educators. Attempts to introduce humanitarian attitudes together with practical skills to key players who form the next generations' moral perspectives and culture are desirable.

Societies and medical professionals in China and elsewhere are facing a fundamental decision induced by biomedicine, which can be assessed either randomly, or based on ethical reflection. The desired character of health care and medicine under the conditions of biotechnology needs to be defined, in order to set up a general policy, together with the related education system. If a market approach is favoured, it will be difficult to argue for practical ethics education. Legal, administrative and technical education would do. If a humane approach is chosen, all pragmatic forces and interests have to be efficiently qualified by ethical criteria. This fundamental decision is going to determine the self-esteem and consciousness of society over a long time. Medical ethics will play a role here, either by an absence of interest, or by enlightened and responsible action.

If the option of the market is taken, the market will "care" for the advanced performance of bio-sciences and medicine. The humane answer, on the other hand, poses new questions and mobilizes society beyond utilitarian aspirations. Medicine with her existential challenges to individuals, for people and for mankind to solve, functions as a catalyst of the discourse of modernization and globalization. In the long range, the impact of ethics will unlikely be restricted to certain areas in society, but has a bearing on our cultures. Culture expresses herself in education. Education has always been both, a timely issue in ethics as well as a topic of intellectual struggles, since the beginning of ethical thinking all over the world.

Ethics education serves us to understand medical practice and to reconsider education. No matter who is being taught and the subject being taught, the "preaching mode" is flawed, not only because it is unethical, old-fashioned, unattractive and counter-effective. In the field where education matters most, that is, for example, in medical ethics. Education ought to acknowledge the nature of human beings and reflect how we wish to become as moral agents. The moral and intellectual advantage of the humane touch in approaching medical ethics education is evident. If the principal is the determination "to do it right", not primarily to obey someone, to avoid trouble, or to get benefits, we can become ourselves. This approach applies to different cultures, transcending both individualistic self-fulfilment and subordinate collectivism.

Teachers in medical ethics carry a particularly heavy burden of responsibility and have a uniquely privileged chance to promote a humane society. It is prudent, reasonable and ethical for any country to educate the educators in medical ethics first. To realize the full importance of teaching medical ethics, one need only take the perspective of being a patient and ponder, what type of doctor he/she would want. This perspective was taken in the preparation of this training course.

4 Prospects

For the foreign lecturers and organizers much was to be learned from this one week's course. We returned home refreshed and inspired, with many new ideas and perspectives, how to make medical ethics education better in the places we work. This was a truly enriching experience in cross-cultural medical ethics. It is planned to revise the concept of the training course, especially in consideration of many constructive and critical comments offered by the participants. The "3 P's" will certainly prevail, whereas the requested "3 times more" require additional efforts in organizing and fundraising. These are minor obstacles, but they have to be solved.

Overcoming institutional and cultural problems on many levels, as in China, demands hard work and determination to resist frustration. However, given the brilliant minds and dedicated hearts who contributed to this event, an optimistic note might be appropriate: Among the Chinese teachers in medical ethics there is much hope for a better future, if they are allowed to flourish according to their capacities. Support and encouragement from the international community of medical ethics is much needed in China. However, for everyone who engages in cross-cultural medical ethics, this is a win-win situation.

Literature

Ann Lewis Boyd and Ole Doering, "Teaching Ethics in Two Cultures", EJAIB Vol 11 (6) November 2001: 184-187.
D. Brown, "The long march to primary health care in China: from collectivism to market economics", Nature Public Health (2001) 115: 2-3.
Chen Renbiao und Qiu Xiangxing, "The Present Status of Medical Ethics Education in the Key Medical Universities in China", in Ole Doring (ed.), Chinese Scientists and Responsibility. Ethical Issues of Human Genetics in Chinese and International Contexts, Mitteilungen des Instituts fur Asienkunde 314, Hamburg 1999: S.45-55.
Michael Cheng-tek Tai (Dai Zhengde), "The Importance of Humanity in Medical Education", EJAIB 10 (3): 84-85.
Ole Doring, "Ethics Education in Medicine and Moral Preaching. Reflections on a Triangular Relationship and its Human Core"", in Ole Doring (ed.), Ethics in Medical Education in China. Distinguishing Education of Ethics from Moral Preaching, Hamburg, 2002: 75-85.
Ole Doring and Renbiao Chen (eds.), Advances in Chinese Medical Ethics. Chinese and International Perspectives, Hamburg (Mitteilungen des Instituts fur Asienkunde No.355) 2002.
Ole Doring, "Moral Development and Education in Medical Ethics. An Attempt at a Confucian Aspiration", in Ole Doring and Renbiao Chen (eds.), Advances in Chinese Medical Ethics. Chinese and International Perspectives, 2002: 178-194.
Ole Doering, "Introducing a 'Thin Theory' for Cross-Cultural Hermeneutics in Medical Ethics. Reflections from the Research Project 'Biomedicine and Ethics in China'", Eubios Journal of Asian and International Bioethics Vol 11 September 2001: 146-152.
Du Zhizheng, "Ethics and Medical Education", in Ole Doring (ed.), Ethics in Medical Education in China. Distinguishing Education of Ethics from Moral Preaching, Hamburg 2002: 27-33.
Dwyer, James, "Primum non tacere: an ethics of speaking up", Hastings Center Report 24, no. 1 (1994): 13-18.
Jiang Zemin, "Editorial", Science 2000 June 30; 288: 2317.
Lawrence, Susan V., "The Sickness Trap", Far Eastern Economic Review, June 13, 2002: 30-33.
Nie Jingbao, "Bringing Ethics to Life: A Personal Statement on Teaching Medical Ethics", in Ethics in Medical Education in China, Doring (ed.) 2002: 63-74.
Wan Huijin, Jing Rongrong, Shi Weixing, "Lun yide jianshi de zhidu chuangxin"("The systematic renovation of the foundations of medical morality"), Yixue yu Zhexue 1999 (7): 23-25.
Yang Huanming, "The Human Genome Project and its Social Impact: to Educate the Educators", in Ole Doring (ed.), Ethics in Medical Education in China. Distinguishing Education of Ethics from Moral Preaching, Hamburg, 2002: 34-44.
Zhu Lilan, "Editorial", Science 1999 January 29; 283: 637.

Acknowledgement

I would like thank and all participants and lecturers for their invaluable contributions and to acknowledge the great help from Ann Boyd, Jim Dwyer, Gerald Neitzke and Nie Jingbao. Without their continued encouragement, stimulation and support, this project would not have been possible.

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