- Dena Hsin-Chen Hsin, M.S.N. (1) 1 China Medical College, Taichung, Taiwan; Email: email@example.com and Darryl Macer, Ph.D. (2) 2 Eubios Ethics Institute, Japan and New Zealand; Email: firstname.lastname@example.org 1 & 2: Doctoral Program in Life and Environmental Sciences, University of Tsukuba, Tsukuba Science City, 305-8572, Japan
The remarkable progress of medical and biological science has advanced the average life that people live to. This means that a growing proportion of human death occurs among older persons. Death becomes less remote for persons as they grow older, with the death of increasing numbers of friends and siblings. We wanted to ask how seniors, persons aged 60 years or older, approach this inescapable end point of their life. Is facing death a positive factor to stimulate a more integrated perspective on life, or is aging or death considered more of a threat that may make people focus only on the decline of their physical abilities making them withdraw from their daily activities?
In the medical environment there is wide cultural variation in the way that senior persons are treated in hospitals. There has been attention paid to the needs of seniors in making treatment decisions, and developments in many countries enhance personal decision-making consistent with the ethical principle of autonomy. When discussing the appropriateness of intensive care and modern medicine to the dying process in elderly persons, we should know something of their life views. Seeking the opinions of seniors is a necessary part of any process that respects their autonomy.
Our personal experience suggests that philosophical thinking about the meaning of life and death are not only popular among professional philosophers but also among people from every walk of life. In order to develop a bioethics for the people by the people we need to understand persons' value systems. While some of these can be gathered come from mainstream values and traditions of our society, there is wide diversity of views of life and the role of medicine in senior years. To look at life and death as a whole should be a core for philosophical studies of the modern perspective of life and death.
There are a range of views towards life that can be seen in different traditions. Biologically speaking, all organisms die but in the process of living have some sense of love of life to survive and reproduce, while in relationships to other beings. From the cosmist point of view, each human being, like the other organisms is but an object to the cosmos. Relative to the eternal cosmos, individual human life is transient. Thus, cosmist law governs death, a definitely existent truth for the human life. The truth of the natural phenomena was realized since ancient times, and all religions have attempted to explain the meaning of life and death. In common Western thinking, learning to die means learning about life with an awareness of death. In eastern thinking the "Neo-Confucian learning of life and death" emphasizes looking at life and death as a whole.
For the site of our study, Taiwan, we would predict that many images of life among the seniors might be derived from the values of Confucianism, Buddhism and Taoism in Chinese culture. However, for most people the values system they hold were not only absorbed from the ancient wisdom or philosophers, but some part may originate from some other sources such as sociobiological mechanisms that appeared through human evolution1, and the beliefs and life experiences inherited from several generations.
How these ancient thoughts are combined with family values and personal practical consciousness of living will be influenced by social norms and could be expected to be dynamic in order to face up to the challenges of the changing world. Thus, understanding both the personal meaning of life and the influence of culture in a certain society or space-time are important. In order to explore seniors' attitudes toward life a questionnaire-based interview was applied to 112 persons in Taiwan. While in many cultures, as in Taiwan, there is some taboo on conversation about death; we focused on talking about the images of life hoping that this might be a way for persons to recall the original ideas about human death before it was twisted by the modern medicine. In Taiwan people are often left on machines for life support well beyond the wishes of families and themselves, and the dilemmas of withdrawal of modern medicine are well known. The issue of control of end of life by a powerful medicine, which regards death as a horror to combat, is an influential image that permeates Taiwanese medical professions that any kind of death should be avoided with full effort and at all costs.
We hope that this would promote an understanding of how people grasp that they must take leave of life and prepare for the end of life. The results may also lead to dialogue of how to make policy to match the Chinese philosophy of a good life and good death. Also it may encourage health professionals to prepare medicine to serve and guarantee a higher humanity in dying.
Because the focus of this study was to better understand the perspectives of seniors about their life, in-depth interviews were designed to gather qualitative data. The procedure involved selection of persons, with a request for an interview. For this survey healthy senior persons of 60 years or older were randomly chosen from several settings were invited as participants, including:
1) Home (living on their own or living without a family member);
2) Community (approaching persons inside a games or sports club);
3) Park (persons were approached in a park);
4) Institution (persons visiting a day care center, residential house, adult college and nursing home).
About half of persons approached for an interview refused. There were more refusals from persons in parks, where less than a quarter accepted. No incentive was offered to people to participate.
Persons who agreed to participate were first given an initial written survey of four questions that asked them to give open responses on their image of life, and expectations from medicine. Secondly, an interview that followed up the initial four written open questions centered on their attitude about life, with a series of a dozen questions was conducted within one week of giving the written request. Concretely, interviewers attempted to explore their values about life in order to find out what people want from medicine for their end of life.
Tape recordings were used during the one to two hour-long interviews. No one refused a tape recording and 112 interviews were conducted in mid-2002 in Taiwan. All interviews were transcribed verbatim, then, data were analyzed by content analysis method to identify key concepts and words that the subjects used. These were then placed into different categories for each question. This article presents the results of the first cluster of questions about the images of life, how they saw their life, what other lives are important and how they saw human's life was related to other lives.
To allow further comparisons the interview results for the question on the images of life in Taiwan were compared with the written answers received from senior respondents in the randomly conducted International Bioethics Survey from 1993 in Japan, New Zealand and Australia.
The sample of 112 persons was gender balanced with 51% female. Of the 112 persons, 52 were from the home group, 30 were from parks and the community and 36 were from institutions. Half (54%) were aged 70-79 years with 23% older and 23% younger. There was a majority (69%) from urban areas. Only 4% were single, but 48% were widowed so only 47% were currently married. Nethertheless only 13% were living alone, 17% were living only with their spouse, 28% were living with their children and their spouse, and 43% were living with their children. Half (49%) had 2-4 children and 46% had more than 4 children. When asked their religion, 20% said they were Buddhist, 19% said Daoist, 20% said I-Kuan Tao, 12% folk religion, 11% Christian and 19% said they had no religion.
The first question in the written and spoken surveys was designed to seek in a non-leading way the images of life that persons had. The question was, "Please express the images which come to your mind when you hear the word of life", and the key words and concepts were placed into categories. A summary of the 172 concepts expressed in the answers from the 112 persons is shown in Table 1.
More than one third of the people (N=44) gave a comment in which himself or herself expressed life as the course of Nature, which someone can hardly predict, or control. This view suggests people have to follow their fate, respecting Karma. We human beings should not expect too much, and just let our life and death happen naturally. Some example comments are:
"The death of a human-being is just like to go out of light, follow the nature is what we can do."
"Birth, age, illness and death - that is human life. You can hardly control or predict it. Just follow the nature. Thus, we do not have to think too much".
"Life and death are decided by your fate, wealth or your fortune is up to heaven."
"Life is nothing to purse, just flowing with nature to reach harmony"
The second most frequent idea was life is "to be treasured" (N=22), because life is short and fragile, and also wonderful and valuable. Many expressed their appreciation of their life by indicating that life is inherited from parents and "Heaven", so that we should take good care of ourselves, protecting and conserving life to the last minute, and nobody (including ones' self) but God has a right to take it back. Very common example comments are:
"Your body, hair and skin are originated from your parents, so they have to be treasured. Take good care of your life."
"Life is a miracle, we have to thank our parents and use it properly."
The third most common comment (N=20) mentioned about health and disease when we talk about life, many of them insisting that life is meaningful only when you have good health. Some example comments are:
"Life, what to say? It was given by heaven with certain assignment, however, without health only prolonging your life, life is meaningless."
"If humans can free of diseases, that's nice. If not, do not prolong too much. You may feel at ease if you do not bother others when you getting old."
Responsibilities of their life and donating it were concepts mentioned by a similar proportion (N=18) of seniors. By donating their life they contribute to their family and children, also country and society, which will make the life of a person meaningful. Some example comments are:
"As a hard worker in the past I feel at ease to endure anything that happens to the rest of my life."
"A person should work hard to pass each of their days"
To enjoy is one of the important things for 18 seniors, as they said, life should be happy and satisfied. Compare to this, to have a long life is not important. For them, to feel at ease is kind of enjoyment, for example:
"Day by day, to live at ease, that is life. I am satisfied with my life.
Some seniors (N=15) gave spiritual comments as the key point of their life, emphasizing the meaning of life as an immortal spirit.
"Life is to behave with your own morality. I am proud to owe nothing to the world, to be flexible and satisfied."
There are those who gave comments that concluded life is a struggle (N=13), full of frustrations and it will never end until a person is dead. However, you have no choice but to face it. As an explanation of struggle in life, one is to pay one's debt of the last life; those seniors can accept their tough fate, to face it with little resistance. As they said:
"To die, the early the better, you will be relieved by your death, …"
"Life is so so, from youth to age, always working hard, it is too much struggle."
"Life is suffering, that is all, especially when you get old…"
Some had a strong idea that life is inherited and should be continued by the offspring (N=10), for example:
"Life should pass from one generation to another; it should be increasing and alternation of generations."
"My effort is only for my children, I hope that they will have enough money to buy a house and have their own business."
Overall in the interviews only four said that they couldn't give any other comment except that life is very hard to define in words. However, some of them needed to have stimulation by repeated questioning and encouragement to answer the questions.
The question discussed above on the "images of life" was also asked in the International Bioethics Survey in 1993 in ten countries across the Asia and Pacific area.7 The answers received in writing from persons 60 years and over in New Zealand (122 concepts from 75 seniors), Australia (72 concepts from 44 seniors) and Japan (63 concepts from 41 seniors) were examined. Because that survey was written the frequency of not stating ideas was higher than in the interview. The written comments were analyzed to compare with the results in Taiwan (Table 2). Many of the ideas are common between these four countries, while Japanese people have most similar comments with Taiwanese such as life is valuable, and death is definite in your life, for example:
"Life was given by parents; is important; received with gratitude (pleasure); but has a limit."
"I want to keep natural fate."
"…And it reminds me that I cannot control my life and the Absolute or the Almighty may dominate it."
Many of the Japanese seniors have the same worry about whether their end of life will trouble others (especially their family). They prefer to choose natural "inochi" (life) instead of a long life that may necessitate one should stay in bed and trouble people around them.
"Though I think I can live longer and be happy, I am wondering whether it should be forced to live longer by treatment. Natural inochi might be good."
"…. I don't want to suffered from an incurable diseases, dementia; *I don't want to trouble others."
"Though it should be protected, it is not needed to live being in bed with old age."
"I regard the importance of life is to endeavor to live until their ends, but sometimes I think I would choose my death if my condition will trouble people around me"
A very popular concept "life should be treasured" was found with a significant proportion in the Japanese group (59%). This kind of idea was derived from the concept that life is limited, following a natural course from birth to death.
"I remember death. And it reminds me that I cannot control my life and the Absolute or the Almighty may dominate it. Therefore life should be taken extremely good care of."
"Life is precious, never recovered if you lose it. Want to take care of it. Everyone will lose (die), however, we would take good care of it until then, and make an effort to live comfortably."
In addition to those categories analyzed through the comments of the Taiwan group, six further categories were used to more fully represent the concepts expressed by persons in these countries. These are new life and growing, other living things, enjoy nature, quality of life and try to live longer (Table 2). The comments from Taiwan were re-examined to see whether these types of comments were also found, but there were few or none.
According to the extended categories, seniors from New Zealand and Australia were more likely to think about living things and enjoy nature. The comments like to share life with others, to see nature from an ecological view and to build a proper relationship with other organisms in the world. When they think about life, they also have more feeling of new life (babies) and growing things. Australian seniors have concrete concepts to emphasize the quality of life. Seniors in Japan and New Zealand expressed their wish of trying to live longer.
In these comments the seniors seldom expressed concrete ideas about being sick, however some in Australia used a concrete idea of quality of life. They also talked about inheritance and continuity of life (N=6, 8%), but in these comments the focus was not on their life or their own offspring, but more on the biological life of the world. Japanese seniors have most similar ideas of life with Taiwanese, however 17% of the seniors in Japan expressed their eagerness for living longer, which did not appear among the 112 seniors of Taiwan. To compare with each other, enjoyment seldom appeared in Japanese life, but responsibility and donation were more popular in Chinese seniors. Also the conclusion of life as a struggle was more common in the responses from Taiwan.
The most popular comments in response to the interview question, "How do you see your life?" were "Just follow the natural way and my fate" (50%). In this category, many of the respondents seem to have Taoist philosophy to see their life is a harmonious action to cooperate with nature, and also to have Confucian philosophy to accept their fate (a type of fatalism). The common words they said were ideas like, "do not think too much", "try to be at peace with myself", "be ready to go", "nothing too violent (struggle)", or "it is my fate". Some example comments were:
"Never think too much or insist on something. It is impossible to avoid."
"What it should be. I always recognize life's pattern and flow with nature."
"I am satisfied to have an ordinary live, even if a big fortune or power can be returned empty".
To give and take, a meaningful life, is another common theme when seniors review their life, given by 32%. There were 36 comments related to this category. People expressed their affections of appreciation, satisfaction and many thanks first, and then recognized their life as a meaningful procedure of processing under the logic of to give and take. They affirm that paying and receiving should be balanced which will make them at peace with themselves and have no guilty conscious.
A total of 27 (24%) talked about their family and children are the core center of life, and they focused their success on dedication to society by donating good children, and feeling proud of children's achievement and recognizing that their hard work is worthy. To get feedback from children as a reward, they concentrated on their children's well-being and on whether their children have a good life. To think about their children's happiness and welfare, many of them hope with all their heart that they won't be a burden to their children during their end of life period.
One category that could encompass many comments was to include the concept that "Since I worked hard, life is now getting easier" (23%). Many of the seniors were satisfied with their present life by feeling easier now. They concluded it was a reward of their working hard in youth. This kind of Karma law can give a reason why people should experience struggle in their life, which was a response given to the general question on their images of life. Moreover, according to their definition, children's achievement means a lot to their easier life. This idea can be combined with the idea of family/children at the centre. Example comments include:
"I have been worked so hard for my early years. Even if I have grievance to my ill-fate, I felt rewarded that my children can behave well, and everything becomes worthy".
"If only my junior family can have a stable life, I have nothing to complain about."
"For the past, it was hard, now, life is getting easier. My future? Depends on my Sons..."
"To bring up my children is my target before, now I look upon things ordinarily, but I will treat myself better."
"I had worked hard to support my children, now they are all well educated (two doctoral degrees in my family). They are all nice to me; I can depend on them for my elderly life. I feel satisfied with the result of life is getting easier."
"… It is worthy to sacrifice for your children, to have an non-filial son or daughter is worse than to die."
For the rest, some (12%) gave a goal for their future "to enjoy the rest of their life". Some (11%) hold a viewpoint that there is nothing but health as their hope in this stage.
Overall except for the key concept of fatalism and flow with nature, the logic of "give and take", " work hard and enjoy", and to appreciate the value of a "worthy" or "reward able" life are very important for seniors to incorporate their past life into their current life view, giving them insight into the present and creating a more inspiring personal future. Children and family is always the main prospect and core centre of this philosophy.
In response to the next interview question, "What are the most important other lives in addition to your own?", a quarter (N=27) mentioned children and grandchildren are the very important other "life", to inherit and continue not only their life but also their own spirit (Table 3). For example:
"Relatives and family, because they can extend to the society. As we said 'govern the family and rule the state' are why family is very important."
"Young generation, everything is in vain if your children are not well enough. What is a useful man? He should behave?"
Only a few (N=9) specifically indicated that their spouse (wife or husband) is practically important to them at this moment of aging. More, 24, commented that their families around them are all very important. Of the total, almost half the comments were related to family members (children, spouse, and family around), that can reveal a central Confucian concept of Chinese people. However one quarter (N=23) commented that there is no life important for them in this stage, they referred to their final life as being hollow (empty), without burden and responsibility, thus nothing is important now. Furthermore, 19 persons raised the idea that nothing is important except them.
Unlike the responses to the general question on the images of life where few mentioned any other lives (Table 1), in response to this more direct way of asking about other lives, 18 seniors thought of the equality of all the organisms (Table 3) and concluded that any creature's life of the world is equal to playing an important role to them. The concept of universal love, equality of beings, and the idea of serving the public were collected in this group. Three seniors insisted that their moral life is most important to their life. For example, to have a good name for their "after-life", and to have their moral spirit prolonged with heaven and earth are very important to them.
When asked how human life relates to other creature's lives one third of the people commented that they have no idea about this concern (N=36). Among these 36, many of them expressed this concern is not within their knowledge (N=14), a similar number said they can not figure out whether there is any relationship between these lives (N=15), while the rest of them said they had never thought about that, and do not know why they have to talk about it (N=7).
Among those who gave a concrete answer to this question, 32 persons realized that humans and animals are mutual owners of the world; they share it and depend on each other to survive. There were also 17 comments on the idea of the equality of beings, that all the organisms are inherited from heaven, humans should respect the power of nature; that is to respect all lives in the world. For example:
"According to the natural law, all species are equal."
"To treat all the living things equally and to respect each other is to flow with nature."
However, there were 11 persons who commented that human beings are at a higher level. While derived from this viewpoint; some said humans have responsibility to protect other animals and some said animals were offered as the food of humans. There are a few seniors who also talked about do-not-kill and having pity on animals as their philosophy to treat other animals. Some mentioned the Buddhist concept of transmigration, that lives will circle between animals and humans, and that it is karma.
Most of these concepts (see Table 1) can be understand through the philosophy of Taoism (especially for categories A, F and G), Confucianism (especially for categories B, H and D) and Buddhism (especially for category G). For many of these elderly people, life should follow its natural course, from birth to death. Everyone has their own Karma. Since there are many things we can not control, thus, it is better to follow your fate to treasure what you have and enjoy it. Among these seniors, some have images of life in society like responsibility to others and service or donation, while others have a practical view that health is definitely important to their life. There are also some spiritual comments about life, and that life is inherited and continuous as a reason for it being very important. Finally life was viewed as a struggle, from birth to death, with some saying we just should follow life and let it be, do not worry and don't think too much, that is life. One striking feature of the interviews was the idea of donation, inheritance and intergenerational continuance of life being seen as circulating around family, parents and children.
Based on the comments given during the interviews, it is apparent that many of the persons interviewed in Taiwan accept Taoist philosophy as their attitude towards their declining life. They easily explained death as a return to nature, or life should return to its source like ten thousand things. Taoist thinking provides a defensive attitude toward their declining life that is "Wu-Wei", harmonious actions and flowing with the nature. We also see how Confucian philosophy influenced people to have a more aggressive attitude to treasure their life, to protect and conserve it till the last moment, for example the famous Chinese saying; "Your every part of body are inherited from your parents, thus should protect it from injury". Both of these concepts are common views that appeared in the lines of seniors' talks, first; a moral life or higher spiritual status may achieve an immortal life; and second, to understand your fate which was decided by heaven can help to reach a fullness of life. To compare with each other, the Taoist thinking of natural harmony is a more popular view among these seniors groups. This can be explained as a trend of retired people to have a more defensive attitude to cooperate with nature and act in harmony with it. For them, to pursue freedom from inner conflict and feel the peace of themselves is the way to adapt Taoist Wu-Wei and to see life as a nature course in order to be at ease with both death or life.
One third (35 /112) seniors mentioned the word" death" on their own initiative when invited to talk about life. While this could suggest that death is a very important part of their life and that they may look at life and death as a whole, most of them admit they feel reluctant to talk about death and dying in front of their family, or people they are very close to. Actually, since they had seen life as a natural course, in their mind they have accepted death as a definite thing that will happen sooner or later. The reason they do not talk about this is also they see death as a natural rule, thus, it is in vain to talk about it or try to control it. According to Taoist thought, once you may recognize life's pattern and flow with them, you will have nothing to be concerned about but follow your fate. People who follow the way of Tao are supposed to be at peace with themselves and free from inner conflict. In this moment we can not tell whether people who hold the Taoist values of becoming one with nature can accept their utmost fear in their last moment, one thing we can sure is that they are free from struggling to live for a long life. However even among those who mentioned death, most feel that dying and death conversations are useless to change what you should be in the future, thus it is not usually chosen as a topic of conversation in people's daily life.
Other than the aging death, an immature death such as to die in an accident or in an inappropriate period of life is recognized as an ill-omen which should be avoided absolutely.6 Thus, in custom, this kind of thinking or conversation is ill favored and in that sense people would see it as a taboo. This may be true of most cultures not just in Taiwan. An aged death of the senior of the family who enjoyed the fullness of life and dies in his home with the young generation around him should regard it as a great fortune of a perfect human life.
There are several seniors in the surveys from Japan and New Zealand who expressed their expectations of trying to live longer (Table 3), while this expectation did not appear among the112 seniors of Taiwan. Some of the Taiwanese mentioned about the idea of "a death that has enjoyed a fullness of age", but none of them expressed they will try to live longer at their age. We can ask whether this comes from Taoist philosophy? Rather we may suppose that senior adults try to restrain their "greed" for a long life to follow Taoist doctrines which the interviews have revealed is a composed manner to accept the reality of death, and according to Tao, to purchase a longer life which merely means to prolong human's suffering.8*************************************************************** Table 4: Ideas on how human life relates to other creature's lives in Taiwan (N=112) Concepts % A. Have no idea (Do not know) 32 B. Mutual owner, share the world, depend on each other 29 C. Equal inheritance from God or Earth, respect nature 15 D. Affection, companion, spiritual dependence 6 E. Do not kill, have pity on them 4 F. Humans are at a higher level - can eat as food 10 G. Karma, circle 6 H. Do not disturb each other, let them be alone 2 I. Other concepts 4 *********************************************************
When elderly people review their own life, moral insight was a key point to conclude the meaning of their life. Tracing back through their dialogue, the formal religion they hold did not play an important role to guide their moral thought. This is consistent with the results of the 1993 International Bioethics Survey across a wide range of Asian cultures. On the contrary, the ambiguous concept of Karma, fate and Heaven are popular in folk-use to explain their logic of sustainable life. For example, people respect and are in awe of Heaven or "Tien" , a scared power and the source of everything. People belief their fate or Karma was inherited from Heaven, with this kind of respect, you have no choice but to accept your fate or Karma. This kind of thought is similar to the Eastern thinking of Indian religion that a person's duty is to preserve the natural order and not to interfere with it. The order has a divine nature and one should enter into it, and any attempt to correct the nature or break the mature Karma is not allowed. With this kind of universal thought, the struggle of life can be explained. Also, because the powerful Heaven can judge your Karma, there is logic to the balance between giving and taking, working hard and getting an easier life which are remarkable thinking which arose especially to the aged people when they attempt to integrate their life.
If people believe in fate, and the flow with the nature, how is it possible to plan in advance for their future death? Is it possible to popularize the living will or advance directives in Taiwanese society? None of the 112 seniors who gave an interview has prepared advanced directives or a living will for themselves. It is similar in fact to the results of recent study in a country that is said to be the epitope of pursuit of individual autonomy, USA, and which actually has a law to offer all persons who stay in hospital a chance to make an advanced directive. The US study finding was that elderly people were resistant to planning in advance for their future death. However, many Taiwanese persons expressed strong views during the interview that some particular health conditions are worse than death. To be a burden on junior families because of impaired health is one of the most terrible things they are concerned about. However, there is no practical action to avoid it. Most people gave an answer like "I will follow my fate, who know what will happen to me?", "My fate, how can I do for my fate?" or "If it happens to me, there is nothing we can do." They said they would even never talk to their children about their concern.
Because of the strong doctrine of filial piety of their junior generation, they prefer to believe that children will do what they can for their best interests at that time. On the other hand, they also are concerned that it will put their children in a conflict situation to think about parents' death. Only few of them said that they will try to set a conversation about that. As the popular saying reads, "It is useless to worry about that, your fate will guide your future, and it is hard to change what it should be." It will therefore be a challenge for health care professionals to make people understand that high tech of medicine makes it possible to change your fate and alter the time and schedule of your death.
People we interviewed were firstly concerned with other life as first; their offspring that is the young generation who will continue the life of the family, and then there are also other families around them who suppose to take care of them till the last minute. This very strong family-centered idea may derive from Confucianism, which teaches that people should love their family first and other persons to lesser degree, as opposed to the philosophy of Mo Tzu who taught of a wider circle of universal love.1 Taoist philosophy has the concept that in nature everything has it place, and everything is valuable,9 while Confucian "relational personhood" emphasizes the love of gradation, and has shaped the culture so that elderly people in Taiwan may concentrate on the relationship of closeness so much, that they can hardly show concern for other living things or show altruistic behaviors to protect them. This could also explain why there are fewer environmental or ecological views of seniors in Taiwan compared to the other countries. While there are affects of the surrounding questions used in the 1993 survey that included some environmental questions, the differences seen in Table 3 between cultures suggest further comparisons will be productive.
Some ideas of do not kill (Ahimsa), equality of beings or having pity were derived from religion, for example Buddhism. However, in Taiwan religions play an ambiguous role to influence people's attitudes to life, thus these concerns of other living things are also not popular in Taiwanese seniors' groups.
In conclusion we have found that a common view is that humans should follow the "Natural" way because life is thought of as a natural course among seniors in Taiwan. The survey has shown that Taoist and Confucian philosophies have important influences upon people's views of life. To follow nature means to flow the way of Tao, which will promote a life in harmony with oneself and the cosmos.9 In this dimension of thinking, most people easily accept the definite truth of their own death as part of the natural process. However, to protect their life and to maintain a healthy body in the meaning to live the "fullness of your time" and what was given by nature is also one's responsibility.8 Thus, the immature or unnatural death is totally different from death as a result of aging. With this consideration, the concept of natural death, free of artificial maintenance therapy for humans' end of life can be understood with no doubt. With this agreement of the public, modern medicine would reconsider it's role to perform a proper end of life care which may promote a higher humanity of dying to the aged people.
Overall in response to this question, when thinking about other lives, these seniors in Taiwan would first talk about their junior generation, which was important to inherit and continue their "after-life". Second, they thought about their spouse or families members around them, who are taking care of their living things and will accompany them for their final stage of life. A significant minority adapted the Taoist philosophy of "Wu-Wei", thinking of natural flow, without seeking to control life, and for them no life is important for them in this stage.
The family-centred nature of senior's life is another key point of their concept of life. Confucian ideas, which lead to the emphasis that the family is the original source of everything were revealed clearly in the seniors group. For example, life is inherited from your parents and ancestors and passed onto your children and offspring. When you are young, your effort is to raise your young generation. Thus, to be provided for when aged by the young generation is such a favorable situation that most expect it as their final target of life. Moreover, a worthy life should be recognized as a good return from your children. Finally, the meaning of life can be achieved by an immortal life, which is continued by ones' descendents. These invulnerable concepts support seniors to face the cruel reality of the decline in their physical and social status. As we may suppose for the welfare of aged groups, nothing, not even full social welfare, or generous medical pay can replace the function of the family to fulfill an aged life. We suggest further international studies should be conducted to examine whether keeping the family tradition is really more common in Chinese society than other parts of the world.
We acknowledge the kind assistance of Ms. Zhao-Yu Chen in helping Dena Hsin-Chen Hsin conduct the interviews in Taiwan. We are indebted to all subjects who were interviewed for the time given to us and their patience. The institutional support of China Medical College and University of Tsukuba is appreciated, but their funds made no influence on the conduct and nature of this study.
 Macer DRJ. Bioethics is Love of Life: An Alternative Textbook. Christchurch (NZ): Eubios Ethics Institute; 1998.
 Konstantin KS. Toward the Bioethics of Individual's Health: Introduction of the Cosmist Philosophical Fundamentals. Eubios J. Asian & Int. Bioethics 2002 Jan; 12(1):2-9.
 Zimmermann V. Learning to die/practice means learning about life with an awareness of death. Revue Suisse de Medecine Praxis 2001; 90(49):2138-43.
 Fuh WS. The Dignity of Life and Death. Taipei: Jeng-Jong Publishing Company Press; 1993 (In Chinese).
 Bowman KW, Singer PA. Chinese seniors' perspectives on end-of-life decisions. Soc. Sci. & Med. 2001; 53(4):455-64.
 Lie FM. Life and death concerns in Taiwanese folk convention. In: Chao KS, editor. Second Level Hospice Care Workshop Program Book; 1996 June 18; Taipei, Taiwan. p. 134-5 (In Chinese).
 Macer DRJ. Bioethics for the People by the People. Christchurch (NZ): Eubios Ethics Institute; 1994.
 Jeng XJ. Chinese Intelligence of Death. Taipei: Dong-Dah Publishing Company Press; 1994 (In Chinese).
 Dreher D. The Tao of Inner Peace. New York: Penguin Putnam Inc; 2000.
 Tai MCT. Natural and Unatural ?An Application of Taoist Thought to Bioethics. In Song SY, Koo YM, Macer DRJ, editors. Bioethics in Asia in the 21st Century. Christchurch (NZ): Eubios Ethics Institute; 2003.
 Kudelska M. The human being ? a cosmic being. In A-T. Tymieniecka AT, editor. Life-the Human Being Between Life and Death. Dortrecht: Kluwer Academic Publishers; 2000. p. 135-144.
 Carrese JA, Mullaney JL, Faden R, Finucane TE. Planning for death but not serious future illness: Qualitative study of housebound elderly patients. BMJ 2002; 325:125-8.
Cheng LF. Stories and common virtue in the Four Books. Taipei: Shyy-Yih Magzine; 1994 p. 75-6, p. 208-14 (In Chinese).
 Tsai DF-C. Ancient Chinese medical ethics and the four principles of biomedical ethics. J. Med. Ethics 199; 25 (3): 315-21.
 Wang BS. The Immoral Life of Confucianism and the Life and Death Wisdom of Taoism. In: Chao KS, editor. Second Level Hospice Care Workshop Program Book; 1996 June 18; Taipei, Taiwan. p. 70-3 (In Chinese).