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7.3. East Asian Family and Biomedical Ethics

- Kenji HATTORI, M.D.
Gunma University School of Medicine,
3-39-22 Showa, Maebashi, Gunma, 371-8511, Japan,

In this paper I would like to examine the basis of East Asian biomedical ethics by paying attention to the fusion of familism and autonomy as a common phenomenon. On a position and role of family in medical practice we have discussed in two different ways. The one is from the perspective of professional ethics. How should a physician or a medical professional do in such a case that a patient's wish and/or interests differ from ones of her family members? This problem is not rare in ordinary medical settings. The other is a matter of due process of the proxy consent for an incompetent patient. When a clinical decision by her family seems to go against her interests, what shall a physician do? These issues are surely of importance. However, here we will inquire about the other issue. It is, namely, a re-consideration of linkage between family-centered culture and medical practices in East Asia. We are concerned with whether the East Asian ethos that drives us to a deep regard and respect for the family is an absolutely admirable virtue or a problem. Now we briefly review the opinions of two authors: one is a Chinese and the other is an American.

1. Family and East Asian autonomy

In East Asia a kind of familism or family-sovereignty has been predominant in medical settings as well as in other ordinary life. Now and then East Asian people talk proudly about it as the essential virtue, which is contrasted to "Western atomistic individualism". East Asian family is an extremely intimate sphere of mutual affection and harmonious cooperation.

It is well known that the leading principle of modern biomedical ethics is autonomy. For example, informed consent presupposes autonomy. In general autonomy is regarded as individual self-determination. It is true, Ruiping Fan remarks, as far as it is understood in a narrow sense or in Western context (Fan 1997). This Western style of autonomy upholds the value of individual independence and self-control. In Western society, "the acknowledgement of dependency is consigned to early childhood only, and subsequently become disguised and suppressed, even when in sickness" (p. 318). Western traditions have required people to overcome their sense of dependence and to achieve self-control as possible.

In contrast, Fan suggests that in East Asia there is the cultural specific form of principle of autonomy that upholds the value of harmonious dependence. This is just "a family-determination-oriented principle"(p. 315). We can easily see this principle working in clinical setting. For example, in the practices of truth telling of a diagnosis or prognosis, informed consent and advance directives (p. 319). Here family is "an autonomous unit as a whole" (p. 317). Besides medical setting, marriage, for instance, is family matter. In East Asian countries the essential ethos is family-centered harmonious self-suppression.

Appreciating Fan's analysis, we must draw attention to two sides of East Asian family-sovereignty, as he notices. One appearance of familism is the following imperative that every agent should be able to decide or act harmoniously in cooperation with other family members. And the other side is that no harmoniously made decisions and actions should be subjected to controlling constraints by other family members (p. 316). Thus, "if a patient refuses treatment because he judges his life is no longer worth living, while the relevant others do not think so in terms of the objective conception of the good, the patient's wish would not be followed, whether or not the patient is competent" (p. 318). It is familiar to East Asian people and seems to be contrary to the concept of autonomy in Western context. That is why some insists that it is impossible and fruitless to import the Western concept of autonomy untouched to East Asian biomedical ethics and proposes that a transformation of conception suitable for East Asian ethos is necessarily needed.

The examination and proportion by Fan is seen to be of value and serves to activate the discussion on the fundamental ground of biomedical ethics. Emotionally we are not unwilling to take sides on his view. However I am afraid that we must confess there are still problems to be explored. Is East Asian family-sovereignty fully well preserved? Does it always work to protect each member's interests? Today does East Asian family have enough power to support and take care of all members? Are East Asian people absolutely negative about individual autonomy? Not considering these issues promptly, let us examine views by a Western ethicist.

2. Family and a duty to die

"A duty to die" seems to be a very peculiar concept, and yet deserves to be deliberated on. It is not an original terminology by an American philosopher John Hardwig. However he gives it a new, elaborate conception; it is rather difficult to confute this conception. Hardwig's conception of a duty to die is that one has a duty to die when she is terminally ill or has serious disabilities and if it is too heavy a burden for her family to care her (Hardwig 2000). Even when she is diagnosed as early stage of dementia, she has a duty to die. She should decline a life-prolonging treatment or water-nutrition supply. She may well pass away with assistance by physician.

What are the grounds for a duty to die? He points out some moments from three different perspectives: medico-sociological, moral and existential. First, modern medicine has made possible easy and longer life prolongation. It also means that the life under medical treatment is getting longer and that mental, physical and social burdens on his family have increased much terribly. His family members are often reduced to a "patient support system"(p.169) and exhausted as cogwheels of the system. That is results of medical vitalism. Second, under this circumstances he, whether a patient or not, should take care of his loved family. He should concern other family members who may have much time left in order to save "their resources | time, energy, emotional support, caring, money"(p.170). If he reduces his loved ones to means to his well being or realization of his desire to live longer, his attitude is blameworthy as immoral. He should abandon his life in this world, if his family members' burdens are greater. This is not a pushy, harsh moral norm. In fact "many older people report that their one remaining goal in life is not to be a burden to their loved ones"(p.122). Thus a duty to die has its ground in the genuine family love. Third, to die early for his family is not simply altruism, but also significant for himself. Because recognizing a duty to die affirms his moral agency and his sense of life in connected to loved others. He is not a selfish man, and responsible to his family in spite of having physiological inclinations. Here we find the source of human dignity. "Pleasure is nice, but it is meaning that matters"(p.135). One can conquer death only by finding meaning in it. That all is a rough sketch of Hardwig's views. It sounds partly like Kantian, partly utilitarian and partly communitarian.

What we must pay attention to is that a duty to die in the Hardwig's sense does not mean one of external, mandatory obligations determined by a society or a government in terms of national interest, but a manifestation of one's the just voluntary, moral conviction in existential settings. Its source is the self-determination based on family love. Hardwig emphasizes the fact that we do not live alone in vacuum, but within our family. That is why he insists a conversion of medical ethics: from a traditional "patient-centered ethics" that is individualistic and attaches too much importance to the patient autonomy to "family-centered bioethics"(p. 99, 135, 166).

To our surprise, at this point we encounter the Asian virtue, harmonious family love, which is contrasted to individualism and the principle of personal autonomy. Then we may be willing to accept his theory of a duty to die? Or can we disregard his theory as a really alien, absurd one in an entirely heterogeneous cultural sphere? Is not it true that who should face and respond to that theory sincerely are, not American individualists, but us Asian biomedical ethicists?

3. East Asian family and a duty to die

So far we have inquire into two outstanding studies. An East Asian ethicist concludes that a kind of familism is the fundamental principle in Asian biomedical ethics. Here familism is contrasted to individualism. An American ethicist proposes a family-centered bioethics on reflections of egocentric patient-centered bioethics. It appears that both views are coincident at the point of criticism of individualism and egoism beyond cultural differences between the East and the West. However this interpretation is erroneous, for Hardwig accuses of, not individualistic self-determination, but egoism. And yet both are in accord as to priority of family as a whole over each member.

Imagine that Fan meets Hardwig. What then? What does Fan say to Hardwig? Probably he disagrees with Hardwig. Because Fan must think it is a duty for other family members to take care of a patient. Namely for him family's duty to care a patient must take precedence over patient's duty to die. It is a heartwarming, human narrative. However, we are afraid this oversimplifies the matter. We have some reasons to mention it so.

First of all, today large family is uncommon, at least in Japan. The trend to towards the nuclear family is progressing. The social structure has changed seriously. Kinship has break down and mutual help in regional community have decreased and grown weak. There are so many families taking care of ill or aged members with great burdens and difficulty.

And yet, secondly, only the myth or narrative that family is a special community bound by love remains and put, as it were, people under a spell. Without any material, supportive foundation, the narrative of East Asian virtue is now alive and prevalent: family for one and one for family. The narrative is surely beautiful but bitter. Under such an idealistic narrative many families get impoverished and not infrequently cases of patient or aged or handicapped abuse are reported. Nowadays family is not, as is generally believed, monolithic and strong.

Thirdly, the more in spite of poor support many family members try to care him, then he might feel all the more small and regard himself as a nuisance. If so, he may well recognize a real duty to die in himself for his straining family and disturbing himself. He might think that he should not keep loved family members caring him so hard. Does not this have something to do with beautiful East Asian virtue of family love?

Finally, few East Asian people are in ignorance of autonomy in the Western sense or human right of self-determination. Rather, the notion of self-determination affects us East Asian people so much, too. Thus it is not unnatural for us to link the imperative of family love with a duty to die. If we were not East Asian people, the reality or an obsession of a duty to die may well be weak. The more family love is emphasized, the more serious a duty to die is. That is the problem that Hardwig gives East Asian people as a present. Family is not the firm, steady foundation of biomedical ethics that always guarantees us safety and solution, but still one of the problems.


Ruiping Fan, Self-determination vs. family-determination: two incommensurable principles of autonomy, Bioethics 11, 309-322, 1997.
John Hardwig, Is there a duty to die? , Routledge, 2000.
Kenji Hattori, Family and self-determination from the perspective of a duty to die, Annals of the Japanese association for philosophical and ethical researches in medicine 19, 151-165. 2001. (in Japanese)
Akiko Miyagi, Family love and "a duty to die" of the patient, Seimei rinri Journal of Japan association for bioethics 13, 61-68, 2002. (in Japanese)

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