Euthanasia,andtheMeaningofDeathandDying:AConfucianInspiration

forToday'sMedicalEthics1
OleDoering
(Publishedin:Formosa Medical Ethics Journal Vol.2, October 2001: 48-66)
InhisintroductorygreetingstotheInternationalMedicalEthicsConferenceattheChungshan
MedicalCollege,Taichung,onMay8,2001,Dr.HuangKunyenoftheNationalHealthResearch
Institutepointedout,"Ifwedonotknowhowtodie,naturewillcareforit".
Thissimplesentencesummarizeselegantlywhatitmeansforhumanstobefree,asrelatedtothe
brutalfactthatwearemortalswithlimitedinfluenceonthewaywearegoingtodie.
1Euthanasiaorphysicianassistedsuicide,fromTheNetherlandstoKoreatoChina
Howshallwemakeitpossibleforpeopletodieinameaningfulandpeacefulway?Thisquestion
burnsallovertheworld,whenevermedicineandnaturecompete.Itisimportantforustokeepin
mindthatourdignityisneitherlimitedbyourbiologynordeterminedbytherangeofmedical
capabilities.Weareresponsibleagentsinchargeofourownlivesanditsmeaning.Themoment
ofdyingiscriticalfortheassessmentofeachone'sentirelife.Thismakesitimperativetobe
preparedforitatanytime.Intheoldandetymologicalsenseoftheterm,allactionsthataimat
providingconditionsforapeacefulandhappydeathrelatetotheconceptof"euthanasia",or
"Anlesi"(theacceptedChinesetranslationoftheterm).Unfortunately,goodreasoningand
lessonsfromhistoryinformusthatthisisthemostriskfulattempttomouldourfates,orto
"assist"someonewholacksthepowertoeithercutormaintainthephysicalbondstolifeby
himself.
TheNetherlands,aneighbourofGermanywellknownforitsliberalsocialpolitics,haverecently
adoptedalawthatlegalizesactive"euthanasia"undercertainconditions.Thisstephasraised
concernsamongbioethicistsandpromptedheateddebatesamongpolicymakersandthepublicin
general.Thisincidencehasreemphasizedtheproblematicsituationofhowtoassessqualityof
1

ThispaperhasbeenpresentedfirstattheInternationalBioethicsConferenceonTheEthicsofLettingDie,May8
9,2001,ChungshanMedicalCollege,Taichung,Taiwan.IamgratefulforsubstantialcommentsbyPaulUnschuld
andNieJingbao.

life,especiallyasrelatedtodyingpatients.Germany'sministerofjustice,HerthaDaeubler
Gmelin,critisizedtheDutchlegislation.Shesaidtheemphasisshouldremainontherapyto
reducesufferingandquestionedtheideaofmercykillings,sayingitinvolved``thedecisionofa
thirdpersononthedeathofahumanbeing.''2
Thetechnicallegalstandardsaremeticulouslydefined.Forexample,underthenewlaw,apatient
wouldberequiredtobeexperiencingirremediableandunbearablesuffering,beawareofallother
medicaloptionsandhavesoughtasecondprofessionalopinion.Therequestwouldhavetobe
madevoluntarily,persistentlyandindependentlywhilethepatientisofsoundmind.Doctorsare
notsupposedtosuggestitasanoption.Inthefuture,casesofactiveeuthanasiawillnotbe
evaluatedbyaprosecutingattorney,asinthepast,butbyanindependentcommission.The
maximumpenaltyforviolationoftheregulationis12yearsinprison.
JusticeMinisterBenkKorthalstoldtheupperhouseoftheNetherlandsthebillformalizesthe
guidelinesadoptedin1993underwhichdoctorshavebeenassistingsuicideswithtacitapproval3.
TheDutchbelievelegalizingdoctorassistedsuicidewillclearupafuzzyareaoflawthathasleft
openthepossibilityofdoctorsbeingprosecuted.``It'sagoodthingthatatacertainmoment
commonpracticebecomeslaw,''Korthalssaid.Infact,thelawseemstocarefortheinterestsof
thedoctors.Thisnotwithstanding,intheweeksprecedingthedebateinearlyApril,theupper
housereceivedmorethan60,000letters,mostofthemurgingthelegislatorstovoteagainstthe
bill.Theantieuthanasiagroup``CryforLife''gathered25,000signaturesonapetition.
AGermanphysician'sassociation,the"Hartmannbund"attackedthelawasbeingastepbackinto
amentalityofeuthanasiaandsuperhumanimageofphysicians,remindingofmedicalatrocities
underNazirule,underthedisguiseofmercykilling.Thephysicianshouldaccompanyadying
patient,"standingbyhimandholdinghishand",butinnowaymayassisttodie.Accordingto
critiquesfromthechurchesandtheconservatives,everyyearabout4000peopleareestimatedto
2

Cf.TheNewYorkTimes,"DutchSenateDebatesEuthanasiaBill",April10,2001.
Cf.twoarticlesintheNewEnglandJournalofMedicine335(1996).VanderMaaset.al,"Euthanasia,physician
assistedsuicideandothermedicalpracticesinvolvingtheendoflifeintheNetherlands",pp.16991705,andVan
derWalet.al.,"EvaluationofthenotificationprocedureforphysicianassisteddeathintheNetherlands",pp.1706
1711.
3

havediedunderactiveeuthanasia,since1994,inTheNetherlands.Moreover,hundredsof
severelyhandicappedpeopleandcomapatientshaveallegedlybeenkilledwithoutanyone's
askingforconsent.TheSecretaryGeneraloftheGermanHospiceFoundation,EugenBrysch,
calledforrealizingtherighttodyingwithdignity.Hepointedoutthataviableconceptofdeath
bedcaremustincludepaintherapyaswellaspsychosocialcare.Asamatteroffact,thevery
definitionofpalliativemedicineincludesmuchmorethanpaintherapy,namelytheconceptof
biopsychosocioanspiritualcareenvelopingthepatientasaholehumanbeing.Italsoincludes
moreactorsthanjustphysiciansandpatients.Beingamultidisciplinaryapproach,palliative
medicineassemblesnursesaswellassocialworkers,psychologists,priests,etc.,inorderto
provideasateamthebestpossibletreatment,accordingtothepatients'needsasanonreduced
humanbeing.Thisapproachofferscomprehensivecare,notlimitedtothereliefofpainandother
physicalsymptoms,butalsoaimingtoprovideallphysical,emotional,mentalandspiritual
comfort.Ithasbeenarguedthattheneglectionofsuchacomprehensiverangeofattentionto
patientsinthemedicineandhealthcaremightcontributetoabiasinfavourofeuthanasia.4
ThisdebateislikelytobecontinuedinEurope,wheremanymonitoringindividualsand
organisationshaveannouncedthattheywillscrutinizeallforthcomingcasescritically.Howis
thissignalreceivedinotherplacesovertheworld?IsuggesttotakealookatSouthKoreafirst,
beinganAsianpluralistdemocracywithalargelytraditionalandpaternalisticmedicalsystem.
TheAPnewsagencyreportedonApril13,"'Mercykillings'areillegalinSouthKoreabutthe
KoreanMedicalAssociation,alobbyfor70,000doctors,hasdraftedanewethicscodethat
wouldgivedoctorsmorediscretionindeterminingthefateofpatientssufferingfromunbearable
painwithnohopetolive.WithoutaclearlegaldefinitionofmercykillinginSouthKorea,
doctorshavebeenuneasywhentheytreatpatientswhotheybelieveareterminalandsuffering
unbearablywithonlyafewdaystolive."
Inawidelypublicizedcasein1998,adoctorinSeoulwassentencedto21/2yearsinprisonfor
allowingaterminallyillpatienttogohomeanddiewithoutfurthertreatmentattherequestofhis
4

IgratefullyacknowledgeMichaelZenzforremindingmeofthecomprehensively"covering"natureofpalliative
medicine.Cf.BuchananMLandTolleSW,"PainReliefforDyingPersons:DealingwithPhysicians'Fearsand
Concerns",JournalforClinicalEthics6(1995):5361;MichaelZenzandFranzJosefIlhardt,Ethikinder
Schmerztherapie,Bochum(ZentrumfrMedizinischeEthik,MedizinethischeMaterialienVol.128)November2000.

wife.Ifadopted,thenewethicscodewouldallowdoctorstodiscontinuetreatmentonterminally
illpatientsontheirownjudgmentorwhentheyareaskedtodosoinwritingbythepatients'
families.Itwouldalsoenabledoctorstorefusedemandsfortreatmentbypatients'familiesifthey
believeit'smedicallyneedless5.
Itisobviousthatthechiefconcernofthislegalinitiative,justasinTheNetherlands,affectsthe
interestofthedoctorstohavegreaterconfidencetobeonthesafesideofthelaw.
InmainlandChina,euthanasia(anlesi),asactivekillingofthepatientuponrequestisillegal.
However,passiveeuthanasia,andthewithdrawaloftreatmentiswidespread,andtherealpractice
isnotwelldocumented.Alongwiththedevelopmentofbiomedicalsciencesandtheriseofliving
standards,theaveragelifespanofpeoplewillbefurtherprolongedinthecomingyears.The
groupoftheagedinthepopulationwillgrow,especiallyasrelatedtotheoverallpopulation,
wherein,asaresultofthefamilyplanningpolicy,theproportionoftheeconomicallyproductive
generationsisdecreasing.Asasideeffect,theincidenceofcancers,heartandbrainvascular
disordersaswellascronicdiseasescanbeforseentogrowbeyondthelimitssustainablebythe
currentlydraftedsystemofhealthcareandsocialinsurance.Eventually,thisdevelopmentwillin
generalmultiplytheoccurringofsituationsofeconomiccrisisforseriouslyillandterminal
patientsandintensifythesocialandeconomicpressureonpatientsandtheirfamilies,generating
therelatedpsychologicalandpsychosomaticindicationsonalargescale.Incidencesof
withdrawalorrefusaloftreatment,whicharereportedwidelyinChina,willincreaseinnumbers,
becausethemainreasonforitisnotthatpeopleingeneralcarelessaboutthewellbeingofdying
patientsbutthattreatmentcannotbeafforded.Thismakeseuthanasiaamostrelevanttopicfor
practicalreflectionsaboutthemeaningofdeathanddying.
QiuRenzonghasexplained,"euthanasiahasbeenthefirsttopicofBioethicsinacademicjournals
aswellasinmassmedia. In1988theFirstNationalConferenceonEuthanasia washeldin
Shanghai.EspeciallytheHanzhongcasestimulatedanationwidedebateoneuthanasiainChina.
In1986afemalepatientXsufferedfromthelatestageofcirrhosis,withseverebedsoresandhad
fallenintocoma.Hersonandtheyoungestdaughteraskedthedoctortodoeuthanasiatoher
5

Inpractice,theborderlinebetweenrefusingtreatment,withdrawingtreatmentandactiveeuthanasiaaretechnical.
Fromanethicalview,focusingontheethicalmaximsofanagent,thisdistinctionisblurred,makingthisgenerallya
caseofconcernforactiveeuthanasia.

withoutconsultingtheirtwosisters.Thepatientdiedfromaninjectionofchlorpromazine.Her
othertwodaughterssuedthedoctorformurderandthedoctorwasarrestedundersuspicionof
murder.In1991,theMiddleCourtdeclaredthedoctornotguilty,thoughhecommittedacrime,
butithadbeeninsignificant.Becausethepatient'sdeathhadbeencausedbythedisease,the
doctor'sactionhadonlyhastenedit,and hismotivewastorelievethepatientfromsuffering.
Thousandsofpeoplewereengagedinthedebateonthe HanzhongCase.About80%ofthem
favoredeuthanasia,but20%spokeoutagainstit.
In1991acaseofvoluntaryeuthanasiawaspublishedinthe BeijingDaily inwhichaterminal
cancerfemalepatientinsistedonherrequestforeuthanasia,anddiedbyaninjection,withthe
consent of her husband and child. This was approved by all medical professionals in the
DepartmentofCancerofahospitalinBeijingCity.Nobodysuedthephysician;instead,the
patient'sdeterminationandbraverywaspraised.In1994,however,thereweresomecasesin
whichtherequestofeuthanasiabyaterminalcancerpatientwasrejectedbyphysicians,andthe
patientaskedfamilymemberstokillherorhim,byusingapillowtosuffocatethepatientor
usingpoisontokillthepatient.Allthosewhotookthisactionwerearrestedandsentencedas
murdererstothreeyearsinprison."6
InthediscussioninChinatheconceptofeuthanasiawasnotmadeveryclear.Beijingbioethicist
ZhaiXiaomeihassuggestedthatanactionsuchasanlesirequiresthatthepatientisinterminal
state and with unbearable, intractable pain and suffering; euthanasia should be insistently
requestedbythepatient;theagentwhotakestheactionshouldbeamedicalprofessional;andthe
means of euthanasia should be painless and dignified as far as possible 7. This definition
resembles the one adopted by Dutch law and favoured by the Korean physicians. Still the
differentsocial,politicalandeconomicsituationofChinaiscrucialfortherealpracticeofany
relevantlaworguideline.Qiureports,"Somepeopleareanxioustolegalizeeuthanasia,butsome

Slightlyabridgedfromhisreport,"MedicalEthicsinChina:StatusQuoandMainIssues",inOleDoering(ed.)
ChineseScientistsandResponsibility:EthicalissuesofHumanGeneticsinChineseandInternationalContexts.
Proceedingsofthe'FirstInternationalandInterdisciplinarySymposiumonAspectsofMedicalEthicsinChina:
InitiatingtheDebate',Hamburg,April912,1998,(MitteilungendesInstitutsfrAsienkundeNr.314),Hamburg,
1999:2432:25.
7
Cf.ZhaiXiaomei,Anlesi:LunliheGainianWenti(Euthanasia:EthicalandConceptualIssues),Ph.D.thesis,
Beijing1998.

arguethatitisnottherighttimetolegalizeit,andthatwhatisneededistodecriminalizeitin
certaincircumstances."8
TheactualimpactofConfucianmoralityontheproblemsofeuthanasiaisfrequentlydiscussedby
scholarsonthemainland.Thediscussionseemstoreflecttheunsettledstageofthedebate.Here
aretwointerestingvoices.Beijinghistorianofmedicalethics,ZhangDaqingsays,"Itshouldbe
notedthatsomescholarsmistakenlyregardtheConfucianteachingsofthesuperiorityof
righteousnessoverlife,andoftheGentlemanswilltoberatherkilledthantoacceptbeing
dishonored,andofthepreferenceofaworthydeathoveraworthlesslife,asarguments
supportingeuthanasia.TheseConfucianconceptsrefertosocialandpoliticalareasoflife,butnot
tothequestionoftheindividualslifeinsituationsofdiseaseoroldage.Confuciansmaintainthat
deathissomethingunwanted.Therefore,noactionthathelpssomeonetodieisregardedasa
virtuousaction.Theconceptoffilialpietyandtheinviolabilityofthebody,(sincelifeisowedto
theparents),havemadeadeepimpressiononChinasculturaltradition.HenceallChineseare
negativelybiasedagainsteuthanasiafortheirelderly."9
ShanghaiphilosopherShenMingxian,ontheotherhand,hasarguedthat,infact,Confucianism
supportseuthanasiaonthegroundsoffocusingonthe"gooddeath"asafunctionofthe"good
life"."Ifweputeuthanasiainthecategoryofthegooddeath,isitpossiblethatChinesepeople
willmoreeasilyaccepttheideaofeuthanasia?Itrequiresustomakemoreeffort,inthefieldsof
academyandpropaganda."10
Inanattempttoenlightenthedebate,LiLufromHangzhouhaspointedoutthat,"Weare
confrontedwithacomprehensiveethicalproblemrelevanttoouroutlookondeath,ethics,and
medicalvalues,whichdoesnotappearinthecaseoftheterminalcare.Developingthecauseof
terminalcarecannottaketheplaceofexplorationofeuthanasiaforofmedicalscience,socio
cultural,andlegalreasons.Alsoterminalcarecannotsolveproblemsthatarerelatedto
euthanasiaregardinglifequalityinsocialmedicine,andthereasonableutilizationofresourcesin
8

Qiu,a.a.o.:26.Itisinterestingthatthedistinctionbetweenlegalizinganddecriminalizinghasbecomeatopicin
Germany'swaytodealwithmattersofpotentiallyhighmoralcontroversy.
9
Cf.ZhangDaqing,"MedicineasVirtuousConduct:AssessingtheTraditionofChineseMedicalEthics",inOle
DringandChenRenbiao(ed.),AdvancesinChineseMedicalEthics.ChineseandInternationalPerspectives,
Hamburg(MitteilungendesInstitutsfrAsienkunde)2001(inprint)
10
Cf.ShenMingxian,"EuthanasiaandChineseTraditionalCulture",inOleDringandChenRenbiao(ed.),
AdvancesinChineseMedicalEthics.ChineseandInternationalPerspectives,Hamburg(MitteilungendesInstituts
frAsienkunde)2001(inprint)

healtheconomics,andcannotdecidewhetherpatientsapproachinglifeendshouldchoosedeath
orsenselesssurvivalwithmentalandphysicalsuffering.Eventhebesthospicecannotremove
theextremepainsufferedbydyingpatients.Scientificandreasonableeuthanasiaisthemost
importantlinkinsatisfyingdyingpatients'wishes,approachingdeathwithoutpityorpain,
improvingourvaluationofdeathandthequalityoflife'send.(...)Asformanydyingpeopleand
theirrelatives,deathisnotthebeginningofsufferingbutthebeginningoffreedomfrom
suffering.Thegreatestpaindyingpatientsandtheirrelativessufferistheneverendingstallingof
death.Inaddition,werethechiefattentiontobepaidtotherelativesinterminalcare,whatshould
wedowhenconfrontedwiththerelativesofthosewhodieofemergenciesoraccidents,who
theoreticallyshouldhavebeenconsoledandpaidattentionto,sincetheyarefilledwithgreat
sorrowforthesuddendeathoftheirfamilymembers,withoutanymentalandpsychological
preparation.However,thisparticulargroupisstillbeingneglectedinterminalcare.Indeed,inthe
fieldofmedicineatlife'sendtherearestillanumberofproblemswaitingtobesolved,both
theoreticalandpractical."11
2AConfucianapproach
AConfucianapproachtoissuesofmedicalethicscanbesignificantforcontemporarydebates
inasmuchasitdoesnotessentiallydependonoutdatedconceptsandrealitiesofsocialandmoral
life.Forexample,ifwedepictConfucianismasessentiallybasedonthepatriarchalfamilyclan
withasprimarysocialandeconomicfunctions,itisgoingtobeverydifficulttocontextualizeit
inasettingofmodernsocieties,withtheirdisintegratingnuclearfamilies,marketeconomic
rationalityandpluralityofsubcultures.Thissocialtrendisobviousinthecurrentsocioeconomic
transformationontheChinesemainland,andappliestoTaiwansinceevenlonger.
Forthepurposeofthispaper,IclaimthatitisconsistenttointerpretetheConfucianClassics
(especiallytheLunyu,MengziandXunzi)asdescribingtheclan/family(Jia)asbeingan
important,yetnotisolatedpartofhumansociety.AsitislayedoutintheDaxue,thefamilyisthe
firstinterpersonalcompartmentofmoralexperiencewhichprepareseveryoneforthebasic

11

LiLu,"BreakawayfromtheMedicalMisunderstandingofApproachingLife'sEnd",inBioethicsinAsia;Norio
FujikiandDarrylR.J.Macer(ed.),Christchurch(EubiosEthicsInstitute)1998:126129

moralunderstandingofhisdutiesandentitlementsinsociallife.However,itisnotakindof
superhumansubjectintremsofaccountabilityandresponsibilityinethicsandlaw.
ThemoralmissionofConfucianismisreachingoutfarbeyondtheconstraintsofaningroup
morality(oramerefamilymorality),byvirtueofitsproceduralconceptofacontinuous
enlargementoftherangeofmoralexperienceandreflection.Thisprocesscontinuesoverspace
(includingallpeopleeverywhere,evenin"barbarianlands")andtime(includingconcernforthe
prosperityoffuturegenerations).Itisgrounded,ontheotherhand,ontheconceptofthereason
capacityandthemoralsenseofeachindividual'sheartandmind(Xin).Toborrowananalogy
fromMengZi,itwouldbeaneedless"mutilation"ofthisphilosophytoregardethicsand
morality,inaConfuciansense,asessentiallyafamilyethic,anditwouldalsobehermeneutically
flawed.12Tothecontrary,Confucianismisauniversalwaytodepartfromonesselfinflicted
(moral)infancy,transcendingthemoralrestrictionsofanysocialsubgroup.
2.1WhoisentitledtointerpreteConfucianism?13
Thequestionofthissubtitlehasbeenputforwardduringthediscussionofmypaper.Asit
appearstorelatetoafundamentalhermeneuticalproblemIwouldliketospendafewlineson
respondingtoit.ThecurrentlackofappreciationofConfucianethicsinTaiwanandmainland
ChinahasitsrootsinalonghistoryofdogmaticpoliticsandideologiesinthenameofConfucius,
renderingtheClassicasocioreligiousiconofconservatismandnotoriouslyculminatinginthe
campaignstopulldownthe"Confuciusshop".Itremindsmetosomedegreeofthesituationofa
generalscepticismagainstthe"Christian"moralsandethicsinmynativecountry.Itwasa
commonsentiment,sharedbymanyintellectuals,topointoutthemoralcorruptionofthe
churches,whofailedtointerferwithatrocities,from"theholyinquisition"toNaziterror,oreven
supportedthem.InGermany,especiallyduringthe1970s,argumentsthatrelatedto"Christianity"
wouldlikelyevokefeelingsassociatedwithbackwardness,culturalsclerosis,ignoranceof
scienceandprogress,conservativemoralismandpoliticalbias.Thisreactionwasobviously
provokedbylongtermbehaviourpatternsofChristianinstituitions,especiallyofthechurches.
Traditionally,thechurcheshadclaimedanabsolutelegitimacyininterpretingthewordsandthe
12

c.f.Mengzi2A6,Hewhoclaimsnottobeable(tounderstandthefundamentalsofmorality)ismutilating
himself.
13
Thispassagereflectsuponthediscussionofmypresentation.Iamgratefulformanyhelpfulcommentsand
clarifyingstatementsfromtheaudience.

spiritofChristianity.Overtime,thispracticeestablishedconfusionbetweenethicalinterpretation
andtheologicaldogmatism,theformerbeingembeddedintherichnessofsocialculture,whereas
thelatteristhebusinessofonlyafewspecializedscholars.Ontheotherhand,aspartofourreal
culture,manyChristianslaymenandindependentthinkershaveaccountedfortheirownoriginal
assessmentofChristianteachings,revisitingoldtextsanddevelopingtheminthelightofnew
secularrealitiesandproblems,withlessemphasisondognmaticagreementwiththeauthorities.
Thishasfedintoageneralpublicdiscoursewhicheventuallygeneratedamoretimelydiversity
ofsocialmores.Accordingtomyhumbleview,theremaybethesameoptionforConfucian,not
becauseitwouldbedignifiedbytheagesbutbecauseitcanstimulateandhelpthecurrentdebate
aboutmedicalethics.
IamhappytoacknowledgethathereIamofferingaparticularinterpretationofsourcesfromthe
Confuciancanon.Thisimpliesthat,firstIdonotbelievethatitishelpfultohingeonagiven
interpretationorcommonunderstandingofConfucianism,beitorthodoxornarratedintermsofa
commontraditionalapperception.Second,myinterpretationdoesnotrepresenttheentirerange
anddepthofrelevantconceptsandapproachesinChinesetradition,butoffersanattempttoa
meaningfulreconstructionofitssystematicreasoninginthelightofmedicalethics.Third,I
recognizethatthereexistdifferentrealpracticesof"Confucianmorality"inChinesesociety,with
anobviousbiasinfavourofjustificationofingroupmoralityandpaternalistic,ifnottosay
authoritarianinterests,whichobviouslycontradictsthesubstanceofmyownreading.This
foundationofsocialmoralityreflectssomepatterns,whichhavedominatedtheofficialConfucian
exegesis,especiallysincethetimesofSouthernSongdynasty,anditprovideslittleillumination
ofourcurrentproblems.
Thereisnoreasontodoubtthat,regularly,students"donotlikeConfucianism",asexplainedby
NieJingbaowithreferencetomainland'seducationandpublicopinion14.Iftheirswastheonly
waytoemploytheChinesetraditionweshouldbetterletitbe.Itwouldbemisleadinganda
wasteoftimeandresourcesinmedicalethicstoreiterateanswerswhichhavebeeninsufficientin
thepasttoapproachtheadvancedconundrumsofourdays.Themajorpurposeofmyproposed
14

Inalettertotheauthor,Niecomments,"Themostimportantintellectualreasonsmaybetheantitraditionalist
culturalorientationin20thcenturyChina.Moreover,socialandpoliticalcrisiticismcannotbeachievedfreely,but
mustbeunderthedisguiseofcutluralcriticism.Inotherwords,traditions,Confucianismincluded,areactuallya
scapegoat."

interpretationistodecodethesepassagesintermsofameaningfulnarrative,consistentinthe
accountofthetextaswellasaccessibleforthecontemporaryreader.Thisdoesnotcontradictthe
philologicalandhistoricalapproach,whichnecessarilyfollowsacertaininterpretativeschemeas
well15.Thisisastrictlyhermeneuticapproach,withaparticularpracticalfocus.Itdoestolerate
differentinterpretations,anditisnotlimitedduetotheodditiesofChineselanguageandculture.
Moretothepoint,thisapproachinvites,requiresandlogicallypresupposesdifferent
interpretationsaspartofthehumanprojecttomakesenseofourselves.
ConfuciusandMenciusspeakalanguageofthepast,theyareinprinciplenotcloserintimeand
culturetopresentChinathantoanyotherplaceonearth.Ourbridgetotheirlessonsisbuiltfrom
thematerialsofphilologicalaccuracy,hermeneuticempathyandreasonableargument.Itrequires
thecomplexskillsofexegeticsciences.Therefore,everyonewhoisabletomaketheancient
sourcesspeaktousinameaningfulwayandwhoispreparedtolayouthisrelatedmethodsand
theoreticalpresuppositionsisentitledtorefertoConfucianism16.Thisisnotanesotericscholastic
mindgamebutaventurethatencouragesgenuineapproachestoethicalreinterpretation,inthe
interestofpeopleinneed.
2.2HowcanConfuciansourceshelpustoassessdeathanddyingintermsofethicsandsocial
morality?
15

IamgladtobeabletorefertothefundamentalgroundworkaccomplishedbyHeinerRoetzinhisoutstandingand
exhaustivephilosophical,philologicalandhermeneuticreconstructionofpreQinConfucianismasmeaningful
sourcesforcontemporaryethicaldiscourse;c.f.TheConfucianEthicsoftheAxialAge,NewYork(SUNYPress)
1993;"The'DignitywithinOneself':ChineseTraditionandHumanRights",in:KarlHeinzPohl,Hg.,Chinese
ThoughtinaGlobalContext.ADialogueBetweenChineseandWesternPhilosophicalApproaches,Leiden:Brill,
1999:236262.LeeMinghuihasofferedabasicphilosophicalreconstructionofearlyConfucianethicsascompatible
withfundamentalliberalismandenlightenment;cf.hisRujiayuKangde,Taipei(Lianjing)1990.LeeShuichuenhas
submittedprobablythemostmatureandcomprehensiveapproachtoBioethicsthroughConfucianconcepts,cf.his
Rujiashenminglunlixue,Taipei:LegionPress,1999.DanielFutsangTsaihasproposedaConfuciananalysisfrom
theperspectiveofmedicalpractice,cf.hisHowShouldDoctorsApproachPatientsAConfucianReflectionon
Personhood,intheJournalofMedicalEthics,2001;27:4450.NieJingbaohascontributedtothenewhermeneutic
ConfucianreflectionofBioethicsproblemsinhistwostudies,"'Humandrugs'inChinesemedicineandthe
Confucianview:aninterpretativestudy",inFanRuiping(ed.)ConfucianBioethics,London(KluwerAcademic
Publishers)1999:167206andAbortioninConfucianism:AConservativeView,ProceedingsofSecond
InternationalConferenceofBioethics,Chuangli,Taiwan,2000.pp.130155.Althoughthesegroundworksmustbe
appreciatedaspartsofanongoingresearchproject,Ibelievethattheirpreliminaryfindingsstronglysupportmyown
hermeneuticdeliberations.
16
Inhisinterestingessay,"Confucianvirtuesandpersonalhealth",NiPeiminarguesthat"thewholeConfucian
projectisintrinsicallyoneofhealthcare",emphasizingthat"healthcareisnotamatterofbiologyalone;itis(...)a
neverendingjourneytowardthehighestperfectionofahumanbeing".InFanRuiping(ed.)ConfucianBioethics,
London(KluwerAcademicPublishers)1999:2744:28and42.

Regardingdeathanddying,theConfucianconceptualhorizondiffersobviouslyfromChristian
understandings,becauseitdoesnotexplicitlyappealtoaphysicalafterlife.Thisfeatureitshares
withtheancientHedonists(e.g.YangZhu,cf.thebookLiezi)andmakesitdistinctfromthe
religiousformsofDaoismandBuddhism.
WhereasdeathanddyingarevividlypresentintheConfucianmind,itiswellknownthatKong
Zididnotdiscussmetaphysicalmattersandtheafterlife.Whatcanbemisunderstoodasa
tabooingverdict,"Donottalkaboutdeath",wouldmoreappropriatelybeappreciatedasa
reminderofouremphasisonlearninghowtoleadagoodlive(whichincludesdying).For
fundamentalepistemologicreasons,wecannotrefertopositivedescriptionsandjudgements
aboutthesituationofdeathinethics.Toacknowledgethatthesequestionsaresubjectfor
reasonablespeculation,leavesroomformoralandreligiousinterpretations,whichmayinform
theindividualassessmentsethicshastodealwith.Itisamatterofprudenceandhonestythata
Confucianperspectivefocussesonourwaystoregardanddealwithdeathanddyingasaspectsof
life.Wearerequestedtoaspireforawayoflifethatisdignifiedatallpointsintime,including
theend,bythemoralstandingofthesubject.Medicalethicsisdesignedtodefinethepractical
provisionswhichwouldalloweveryonetoliveagooddeath.Thisdemand,however,doesneither
includeageneraldutytodiscontinuealifethatfailstomeetsuchstandards,nordoesittolerate
notcaringforapersoninneed,disregardingageandmerits.
DeathanddyingaremomentsinaprocessoftransformationoftheDao17.Asanagent,every
humanbeinghasthecapacitytoactivelytakepartinthistransformation.Theultimategoalitisto
liveagoodlife,namelytorealizeandmanifestourmoralcapacitiesinwhateverwedo,willing
onlywhatisgoodinitsownright.Deathanddyingshouldbeunderstoodasbelongingwithinthe
scopeofsuchagoodlife.

17

Cf.LeeShuichuen,"AConfucianAssessmentof'Personhood'",inOleDringandChenRenbiao(ed.),Advances
inChineseMedicalEthics.ChineseandInternationalPerspectives,Hamburg(MitteilungendesInstitutsfr
Asienkunde)2001(inprint).IwouldliketopointoutthatthisconceptoftheDaorepresentsConfucianismaswell
asearlyDaoistphilosophy,asrepresentedbyZhuangZi.ThetopicofDaoasthe"circleoflifeanddeath"according
tothisschoolneverthelesshasadifferentemphasisontheonenesswhichtendstodisregardtheparticularinterestsof
thelivingpart(intheabsenceofa"realandtotaldeath"),promotingatranquilandjoyfulattitudetowardsdyingasa
merestageincontinuoustransformation.

Everyhumanbeingbynaturecherishesphysicallifeassomethingmostvaluable,owingto
parents,forefathersandsociety.Yet,themeresensualexistenceismeaninglesswithouta
constantorientationandadjustmentaccordingtoourinbornmoralsenseandurgetodowhatis
right18.Thisincludesourinterpersonalrelationshipsaboveallothermatters.Aslongasweare
healthyandfullyfunctioningagents,attentivetoourinbornknowledge,themoralsensedoesnot
failtomoveandmotivateus,inaquitephysicalsense.Forexample,ifweseeachildfallinginto
awell,ourimmediateimpulseistorescueit(withoutanysecondthought);ifweareconfronted
withthevisiblesufferingofacreature(evenanox),wesenseoriginalsympathy;ifwecome
acrosssituationsofgrossviolence,wespontaneouslybegintosweatandturnawayoureyes19.Of
course,thisinfantstateofourmoralsensehastobeinformedandcultivatedbyourreason(Xin,
Ren,Yi),inordertofunctionasareliableguidewithinthisconfusingworld.
ThegeneralattitudeofaJunzi(nobleman)istoliveahumanelifeaccordingtoRen,andtobe
guidedinhisactionsbyhismoraljudgementofrighteousness(Yi).
Dyingofthebodyisintrinsiclyconnectedovertimewithourphysicalexistence.Agoodlifeisa
lifewheredyingwouldnotbefearedatanypoint.However,aslongasweareabletolivea
meaningfullife,thereisnojustificationtoacceleratedying,andanunnaturaldeathmustbe
avoided.Eveninrareandextremesituations,whereitappearsappropriatetodieaswellasnotto
die,itisbetter(thatis:brave)tocontinuelife,asanimperativeofthevirtueofunselfishness20.
Thisdoesnotsuggestanegativeorcarelessattitudetowardsthebodyonthesideof
Confucianism.Infact,greatphysiciansandmedicalscholarssubscribedtoConfucianethics,
fromSunSimiaotoSunYatsen21.Ourphysicalnatureisvitallyinstrumentalforhumaneness,
butnotanendinitself.Thereforewemustnurtureandrefineit.
AtthebeginningofthebookJinXin,MengZisays:"Hewhohascompletelyrealizedthe
capacityofhisheartandmindunderstandshisnature.Byknowinghisnatureheunderstands
18

Mengzi6A10.
Mengzi3A5.
20
Mengzi4B23.
21
Cf.eg.ZhangDaqingandChengZhifan,"MedicineisaHumaneArt:TheBasicPrinciplesofProfessionalEthics
inChineseMedicine",HastingsCenterReport,Specialissue,JulyAugust2000:812.Thefactthatmanyscholars
refertosomekindof"Confucian"inspirationinrecentmedicalethicsrelatedliteraturedoesnotsuggestthatitis
actuallylegitimatetoaddressthequotedphysiciansasmodelsforaConfucianBioethics.AlthoughIstronglyargue
infavourofareconstructionofConfucianethicsintermsofcontemporarymedicalethicsissues,Iacknowledgethat
suchaworkshouldbebasedonsolidphilologicandhermeneuticresearch.Theverymeaningof"Confucianism"is
partofarelatedresearchprogramme.
19

Heaven(ourhighernature).WeserveHeavenbypreservingtheheartandmindandby
nourishingour(inner)nature.Ifthecultivationofone'sselfaccordingto(thehighernature)isnot
disturbed,byprematuredeathorunnaturallylonglife,we(can)establishourselvesuponour
givenfate."22
Thispassageexpressestheideaofanindividuallygivenlifespan,whichisneithercutoffnor
arbitrarilyprolonged.Byallmeansweshouldtrytoavoidaprematuredeath.Ahumane(Ren)
personistranquilandhealthybecausehefocussesontheessentialsoflife,nourishingnatureby
morality."Thosewhoarehumaneshalllivelong"23.Itisthereforirresponsibletostandundera
tremblingwall24andtotravelareasofwarwithoutstrongreasons.Dyingnaturallyatoldage
mustbedistinguishedfromaprematuredeath.Everyonehastheobligation(towardshimself
andhisrelatives)tofulfillhisgivenlifespanandtomakebestuseofit.Ontheotherhand,
society,physiciansandpoliticaldecisionmakershavethedutytoprovidethenecessary
conditionsforeveryone'slifetobecomefulfillableandtoassisteachothersinthisquestasbest
aswecan.Thisreferstoeveryone,includinginfantsandprenatalhumanbeings.
Yet,howdoesthisconceptofanaturallifespanmakesenseunderthegivenconditionsof
invasivebiomedicine?Wehaveachievedastateoftheartofmedicaltechnologythatrendersthe
ancientintuitivecertaintyoftheconceptofanaturaldeathhardtomaintain.Assoonasweare
abletointroduceartificiallifesustainingmeasures,a"natural"or"mature"deathcannotbe
inferedfromtheempiricaldescriptionofacaseofdeath.Instead,itbecomesasubjectiveissue
whichlargelydependsoneveryindividual'sunderstandingofhisorherfulfilledandmeaningful
life(anddeath).Atthesametime,theverdictagainstanarbitrarilyprolongedlifedoesnothelp
usmuch.Historically,itisaimedagainstsomereligiousDaoistattempts"toovercomedeath".
FromaConfucianview,thefearofdeathisalwayssecondarytothemotivationtoberighteous.If
theobsessiontocontinueone'sphysicalexistenceoverrulesthedeterminationtorealizeone's
moralcapacities,thislifebecomesmeaningless.However,inmanycases,modernbiotechnology,
togetherwithpaintherapy(orrelief)andsociopsychologicalcounselingoffersarealchanceto
Mengzi7A2.
Lunyu6.21.
24
Mengzi7A2.
22
23

maintain,andeventoregainameaningfullife.Therefore,itgoesquitewellhandinhandwiththe
Confucianconceptofagoodlife,althoughwemaynotrefertothislifeasbeing"natural"ina
naivesenseanylonger.Aslongasahumanbeingpreserveshiscapacitytoactaccordingtohis
deontologicideal,hedeservestoreceiveallduesocial,spiritualandmoralrespectandbest
treatmentofamoralperson.(Thisstatementimpliesnojudgementaboutwithdrawingtherespect
iftheseconditionshaveseizedtopersist).
Asaconsequence,wecannotsimplyrefertonaturaldeathanymore,butshouldfocusonthe
meaningfullifeofthepatientandtheconditionsfordyinginasenseofhavinglivedafulfilled
life.Oneshouldbeabletodieatease,exactlybecauselifehasbeenmeaningful25.Inamedical
context,thisurgesustohighlighttheinterpersonalrelations,includingtherelationshipbetween
doctorsandnursesandthepatient,thefamilyandsociety,togetherwithourunderstandingof
care,asanavenueofmorallife.Inasmuchasotherpeoplearerequiredtomakesomeone'slife
meaningfulthenatureofhumansassocialbeingsurgesustoapproachethicalproblemsin
medicineintermsofinterpersonalrelationandtheirgoverningprinciples.
ThefirstandmostgeneralethicalprincipleinConfucianismishumaneness(Ren).Ashuman
beings,wecannotpracticeRenwithoutrighteousness(Yi),andwecannotunderstandYiwithout
Ren.OneofthefunctionsofRenisfilialpiety(Xiao).Asanoriginalmoralsense,itissomething
thatcannotbelearnedinthefirstplace,butisbornwitheveryhumanbeing26.
BecausefilialpietyisoftenbelievedtoconstitutetheverycoreofConfucianethics27,Iwould
liketoclarifythatthisisnotthemostappropriatewaytomakesenseofthisconceptandits
ethicalframeworkforourpresentpurposes.TheClassics,atleastdonotrecommendasucha
wayofreading.Addressedasavirtue,Xiaoisexpresslycalledavaluable"fruit"(Shi)of
humanity,anapplicationofRen,andafineseedfromwhichtocultivateanattunedmorallife28.
Inthesamelineofthought,itisimperativetolearnhowto"treattheolderasanolder"(zhangqi
zhang)29,the"brotherasabrother",andsoon(includingtheotherthree,husbandwife,ruler
Mengzi1A3.
Mengzi7A15.
27
Forexample,cf.FanRuiping,SelfDeterminationvs.FamilyDetermination:TwoIncommensurablePtrinciples
ofAutonomy,BioethicsVol.11No.3&4,1997:309322
28
Mengzi4A27.
29
Mengzi4A11.
25
26

citizen,friendfriend,thatmaketogetherthe"FiveRelationships",WuLun).TheConfucian
programmeofthe"restitutionofcorrectnames"(ZhengMing),thatisingeneralattemptingto
establishamorallytruthfuluseoflanguage,withregardtohumanrelationshipsexploresthe
concretenormativeimportofhumaneness(Ren)asrelatedtoalldifferentkindsofsocial
relationship.Theprinciplesofhumanenessandrighteousnessareadjustedbysociomoral
empathy,orreciprocity(Shu),whichshouldbepresentinallinterpersonalrelationsifwewishto
doright.Inprinciple,thereisnoregionallimitationoftherangeofhumaneness.Itisthevery
natureofhumanbeingstobecapableofrealizingtheirmoralcharacter.
Xiaomustgoalongwithrespect(Jing).Ifitdoesnot,itmeansnomorethancaringforhorsesand
dogs30.Theneedsofthebodyarenotall.Thesufferingsofthepatientsgobeyondphysicalpain.
Infact,respecttobiologyshouldnotdominatebutberegardedassubordinatetomeaningfulness
anddignity.Thiseffectsourattitudestowardpatientswhofacea"certaindeath".Peoplewith
multipleorganfailure,forexample,orcnacerinthelastterminalstate,cannotberegardedas
livingcadaverswhojustwaittopassaway.Dyingpeoplearealiveaslongastheyarenot
positivelydead.Theydeserveandneedthebestofourhumanity,thatistopreparethemtodiein
ameaningfulanddignifiedway.Theappropriatewaytorespondtoqueuesofpeoplein
emergencyroomswhowaitforthedyingone'sto"resumethebed"isnottorushbuttocallfor
morebeds,morepersonellnadbetterfacilities.Howcanwemaintaintheethicalimperativeof
medicine,wheninthemostcrucialmoment,wherehumanitymustovercomebiology,we
calculatethefutilityofoddsandresorttothebiasedconceptionandlanguageofutility.The
burdenandjoyofcarecannotbecarriedbythecaretakersbutbythecaregiversonly,thatisany
civilizedsociety.Wheneverwecare,weshouldtakeourtimeandpayutmostattention.Ifcaring
isnotarealpleasure,ifcaregiversonly"pretendasmilingface"thanitishollowandunethical,
namelywithoutRen.31Thisismostevidentlythatthisreferstodyingpatientsinparticular.
MengZimakesitquiteclearthatthe"parentsofothers",orelderlypeopleingeneral,aretobe
includedinourmoralconsiderations."Treatwithrespectduetotheagedyourownfamily's
elderly,sothatyoubecomeabletotreattheelderyinotherfamiliesalike.Treatwithaffection

30

Lunyu2.7,2.8.
Lunyu1.3,17.15.

31

duetoinfantstheminorsinyourownfamily,sothatyoubecomeabletotreattheinfantsinother
familiesalike."32
Moregenerally,solidaritywithpeopleinneedanddespairisimperative33.Itisthecommittment
ofthestatetomakethepeoplewealthysothatnoonelacksthebasics34.Whereastheprincipleof
humanenessrelatestoallhumanbeings,thewaystoactaccordinglymaydiffer,accordingtothe
actualrelationshipbetweentheagentsinvolvedinagivensituation.Forexample,ifIfind
somebodybeingabouttomurdersomeone,Ishalltrytointerfere.Yet,Iwilldosoinamore
moderatemannerincaseofastrangerthanincaseofsomeonecloselyrelatedtome,becausethe
strangermightratherlistentothatkindofintrusion,andtherelativemightbemoreperceptivefor
myemotionalanddirectplea35.Itisamerematterofprudencetoapplytheuniversalprincipleof
Renonthebasisofsoundinformationaccordingtotherespectivesituation.
Inclearcontrastwithacommonpreoccupationthatrendersunconditionedreverencetowards
one'sparentsanintrinsicconceptofConfucianism,Confucianethicsdoesexcludeanynotionof
anunqualifiedmaterialprincipleinethics.Allprinciplesarequalifiedbytheirrelationtothe
regulativeprincipleofRen.(ThisappliesfortheassessmentofRenasavirtueaswell).Allmoral
dutiesarereciprocal.AKingmayonlybecalledaking(Wang)ifheembodieshighestvirtueand
servesthepeople,orelseheiscalledatrueusurpator(Ba).Parentsmustrespondtofilialpiety
withparentallove(Qin),whereaschildrenowethemgratefulnessandrespect36.Onlythe
systematicreciprocityofourmoralobligationsmayrepresentthewealthandmeaningfulnessof
Reninchangingsocialsituations.
Therebyweareencouragedtobeindependentthinkersandjudgesbyourselves,astohow
humanenessmustbeobservedinanygivensituation.Accordingly,itisthehighestgoalinethics
educationtoencouragethestudents'heartsandmindstocultivatetheirhumanenesssoasto
preparethemforindependentandcreativereasonablejudgementandflexibilityunderchanging
situationswithalwaysnewpeopletocareabout,butnottomakethem"repeatwhattheteacher
32

Mengzi1A7.12.
Lunyu16.4.
34
Lunyu13.9.
35
Mengzi6B3.
36
EvenXiaocanberationalizedasbasedontheexperienceofparentalcare,whichdemandsreturningcaretothem
whentheyneedit,orto"givebackthroughthreeyearsofgrief"forthedeceased.Cf.Lunyu17.19.
33

says"37.Forexample,foramatureadulttoplaythefoolishchildinfrontofhisoldparentsin
ordertoentertainthemasa"goodson",iftheywillso,isnotonlyaperversionof"filialpiety"
(Xiao),butalsoaviolationofhumanenessandrespectduetotheparents38.Ayoungmandoesnot
underallcircumstanceshavetoaskhisparentsforpermissiontomarry,because,evidentfor
everyone,itistheintrinsicimperativeofXiaothathebuildsafamilyinordertoprocreateand
henceitistherelatedparents'dutytopermititanyway39.Thegeneralmoralrules(Li),acommon
setofinstructionsincludingmodelsformoralaction,arenotdogmaticprinciplesbutsubjectto
interpretationaccordingtotherealcontextofanaction(Quan).Whereasitwouldbe
inappropriateforamantotouchthehandofhissisterinlawunderconditionsofregularsocial
life,itwouldbeamoraloutrageifherefusedtolendherahelpinghandtorescueherfrom
drowndinginapool40.Situationsofemergencyorotherurgentnecessitiesorunprecedentedcases
stronglyrequireourmoralsensestoactfreely,withoutrespecttoanyoftheelaborateruleswhich
mustbefollowedundernormalconditions.Thishasaparticularimpactonmedicalethics,
becausemedicalsituationsareregularlysituationsofcrisis,emergencyandexistential
necessities,withoutroomforsociomoralniceties.Independentmoraljudgementonthebasisof
welltrainedpracticeofRenisthereforeabasicqualificationformedicalprofessionalsinspired
byethics.41
3CantheDutchlaw,oranygivenlaw,beamodelforKoreaandChina?Theimperativeof
care
Inthislight,IwillnowinvestigatetheDutchlaw,asapotentialmodelforothercountries,witha
specialinterestinitsapplicabilityindifferentsocioeconomicandculturalsettings.Thelaw
definesthreemajorcriteriaswhichcombinedconstitutethetermsunderwhicheuthanasiamaybe
performed.Thepatienthasto(1)experienceirremediableandunbearablesuffering,(2)beaware
37

Cf.OleDring,"MoralDevelopmentandEducationinMedicalEthics.AnAttemptataConfucianAspiration",
in:OleDringandChenRenbiao(ed.),AdvancesinChineseMedicalEthics.ChineseandInternational
Perspectives,Hamburg(MitteilungendesInstitutsfrAsienkunde)2001(inprint).
ThisincidenceisnarratedinXiaojing10.
Mengzi4A26.
40
Mengzi4A17.
41
AninterestinginterpretationofChinesetraditionalthinkingaboutsuicideandeuthanasiaisofferedbyLoPing
CheunginhisessayConfucianViewsonSuicideandtheirImplicationsforEuthanasia,inFanRuiping(ed.)
ConfucianBioethics,London(KluwerAcademicPublishers)1999.Alsocf.GeorgeKhushf'scommentinthesame
volume.
38
39

ofallothermedicaloptionsand(3)havesoughtasecondprofessionalopinion.Therequesthasto
bemadevoluntarily,persistentlyandindependentlywhilethepatientisofsoundmind.Ishall
takethethirdcriterionforgrantedhere,thatisprofessionalcountercheck.Fromanethical
perspective,Ihaveseriousdoubtsaboutthefirstandthesecondcriterion,namelythatacertain
degreeofpainmustbediagnoisedandthatthepatienthasto"beawareofallothermedical
options".
Astopain.Atthefirstglance,thisappearstobequiteahumaneandpracticalcriterion.However,
closerempiricalinspectionrevealsthatitishighlyambiguous.Howdoweknowaboutagony,
andwhodecideswhetherourunderstandingandrelatedactionisaccurate?Whatisthenatureand
causeofpain?Physiciansinpalliativemedicinereportmanysituationstheydescribeaspainin
realitybeinga"cryforhelp".Weoughttobearinmindthatacutepainusuallyfunctionsasa
naturalindicatorforproblems,anditisourtasktostudythislanguagedeligently.Whereasacute
painmaysuggestthatacurativemedicalapproachisindicated,chronicalpaincannotbetreated
inthesamesense,butcallsformorecomprehensiveapproachestopainmanagement,whichmay
includesufficientquantitiesofnarcoticanalgesics,especiallyfordyingpatients.42Tobasean
actiononamistakenunderstandingofthecauseofpaincaneasilyresultintorture,especiallyif
thepatientisentrappedinaweakbody.Painmayindicatethefeelingofmeaninglessness,
abandonment,unresolvedproblems,andsoon,amountingtoacomplexsociopsychological
syndrom,expressedthroughpsychosomaticsymptoms.Unfortunately,painresearchisfairly
underdeveloped.Oneoftheleadingexpertsandpioneersinpainresearchandpaintherapyin
Germany,MichaelZenz(ofBochumuniversity)emphasizesthatonlyasmallproportionamong
thepatientswhoexpressthattheywanttodie,ordemandtohavetreatmentwithdrawn,actually
wishtoendtheirlifebecauseofunbearablepainbutbecauseofareluctantapplicationof
morphin.Infact,caseshavebeenreportedwhichsuggestthatlackofmedicalattentionoreven
malpractice,suchasinaccurateadministrationofdrugs,orimproperresuscitation,mightmotivate
someofthesepleas.Patientsmaydesiretoescapeasituationtheyperceiveasatrapwithnoother
wayout,byseekingdeath.

42

Cf.ZenzandIlhardt(2000):9f.

Astothe"options".Ibelievethat,first,"allmedicaloptions",asconventionallyunderstoodina
senseofcurativemedicine,arenotnecessarilysufficienttohelpthepatient,(eveninmedical
terms).Evenifweacceptthecurativeparadigm,itremainsdifficultinmanycasestodefinethe
accurate line of medical futility. Also, the range of medical options is not exhausted where
painkillers and technical devices fail to have an effect. The art of medicine invites doctors
togetherwiththenursingteamtobecomeinterdisciplinarilycreative,changingperspectivesin
ordertoinventadaptablemeasuresforindividualsituations 43.Physiciansshouldbeencouraged
andallowedtoresorttothesourcesoftheirprofessionalandhumaneimagination,seekingnew
waysinhealingandcommunicatinghopetothepatient.Theoldremedyofthe"humantouch"
couldbestrengthenedagaininclinicalpractice,permittingthemembersofthemedicalteamto
share their genuine affection with the suffering patient and being present as companions in
bedsidecare.Both,therapyandnursingdeserveitthatmoretimeisspentwithandonthepatient.
Thefactthatrealclinicalconditionsfrequentlyruleoutsuchahumanemedicinedoesnotdefeat
myargumentbutpointsatflawsinthepresentsystem.Theseflawsshouldbemended,giventhat
wereallywishtoachievethebestpossiblemedicalsystem.Andtheyprobablycouldbehealedin
thespiritofPalliativecare,thatisthespecialcareofapersonwhosediseasenolongerresponds
totreatmentaimedatacure.PalliativeCarehasthegoaltoprovideasmuchfreedomaspossible
fromsuffering,bygivingphysical,emotional,mentalandspiritualcomfort.Ittriestorelieve
fromsufferingandtopromotethebestqualityoflifeforpatientandfamily.Asitdoesnothasten
ordelaydeathitdoesnotplayabiasedroleineuthanasia.Itfocussesonahumandiversiryof
symptoms, ranging from pain over depression, fear, loneliness, and the search for
meaningfulnesssorGod.
Second,IwouldliketorespondtotheDutchlawthatinsituationsofseverechronicpainthe
curativemedicalapproach,evenifbasedonthemosthumanepurposes,isnotthebestwayto
treatapainpatient.Forchronicpainpatients,palliativemedicineinitsoriginalsensesuggests
itselfasprobablythemoreethicalapproach.Interestingly,hereaConfucianassessmentmeetsin
substancewiththestateoftheartin"Western"medicine44.Therearemanypracticalwaysin
43

Cf.ZenzandIlhard(2000):10.
InreferingtothestateoftheartIdonotwishtosuggestthattheadvancedcountriesofEuropeandAmericahave
alreadydrawnthepracticalconclusionsfromsoundtheoryandevidenceonallrelevantclinicalandsociallevels.For
example,c.f.MichaelZenzet.al.,"SevereUndertreatmentofCancerPain:athreeyearSurveyoftheGerman
44

whichtoprovidemeaningfulnessforsomechronicalpainpatientandrestoreasenseof
belonging,helpinghimtorestorehisstrengthtoendure,assistedbyreasonablemedications.
Someofthemincludedirectinterpersonalactivities,whichreinstallthesenseofappreciationof
thepatientasahumanbeing.Wecouldbemorecreativeandinventnewmethods.Why,for
instance,arewekeepingelderlypeopleapartfromchildren?Forexample,manyoldpeoplemay
simplymisstheeasymindofachild,meanwhilemanychildrengrowupwithoutasenseoftime
andhistory.Whowouldnotprefertoliveinasocietythatbringsitslonesomechildrenand
abandonedseniorsnaturallytogetherformutualbenefit,ifthisisfeasible?Palliativecareand
hospiceworkoughttobeconnectedwithsocialcounsellingandsocialworkofmanykinds,
whichmightopennewopportunitiesforthepatienttoconnecttolife.Suchapolicywillwithno
doubtenrichsociety.
IdonotrecommendthattheDutchlawshouldbeamodelforlegislation,neitherinKoreanorin
China.Atleast,itdoesnotcaterfortheinterestsandtheneedsofthepatientsfirst.Itisclearlyin
theenlightenedinterestofdoctorswhodonotwishtoworkina"fuzzyareaoflaw".Intheir
work,theydependuponalegallyviabledefinitionofallowedandnotallowedpracticesof
"euthanasia".Thisisbyallmeansalegitimateinterestonthephysicians'side.However,not
withstandingthislegitimateclaimforlegalsafety,thefocusofethicsincludesthelegitimate
interestsofallpartiesinvolved,withaspecialalertnesstothelessprivileged.Suchalawcouldbe
practicalatbestassmallpartofagreaterprojecttoreformsociety,withanemphasisonhealing
thecountry,thepeopleandthediseases.Asithasbeendiscussedintheconference,itseemsthat
aboutsixlawsuitshadbeenfiledagainstdoctorswhohadwithdrawnlifesustainingmeasures
accordingto43oftheTaiwaneseHealthCareLaw.Itiscertainlyagreatsuccessofpatient
rightsmovementandcivilsocietythattherespectivelegaltexthasbeenrevisedandthatthe
revisionisnowinforce.However,whywasthisinitiativenecessaryinthefirstplace?AsTsai
Futsang(TaipeiUniversity'sMedicalCollege)pointedout,therevisionmakesnodifferenceas
regardstherealmedicalsituationanditsprofessionalandethicalevaluation.Nodoctorhadbeen
foundguiltyofanycrimeoroffenceundertheconditionsoftheearlierlawwhowouldnowgo
unpunished.Evenundertheoldlaw,relativescouldhaveaskedforcondemnationofa
resusciationpracticethatbecomesunethicalwhenitismoretorturethanassistance.Therefor,the
situation",JournalforPainSymptomManagement,10(1995):18791.

revisionofthelawdoesnotreallyhelptochangetherealsituation.Butnevertheless,itmight
haveitsmostsignificantoutcomeinreducingtheincidenceoflitigations.Itseemstocatermore
foraninteresttokeepalowpublicprofile,accordingtothemotto"nolegalaffairisagood
affair".Thisbiasisnotrecommendedundertheconditionsofademocraticsocietywhere,infact,
thepublic'sattentionprovidesakeytolegitimacyandcompetentindependentjudgesguarantee
fairness.Whatwouldbewrongiftherewereevenmorelawsuits,giventhatmedicalpracticeis
continuouslyperformedonthebasisofbeststandards?Manycountrieshavelearnedtolivewell
withlegalchecks,asameanstocontrolandremindphysiciansoftheirpeculiarsocialand
individualresponsibilities.Ontheotherhand,ifcitizensdonottrustintheirlawsandcourtsbut
feelthat"alawsuitisasentence,nomattertheverdict",thisindicatesaseriousproblemonthe
sideofpoliticalcultureandlegitimacyofconstitutionalorgans.Thefocusonpositivelegalaction
undertheseconditionscanbemisleadingifthefundamentforastateoflaw,namelyabasic
socialconsensus45,isnotwellestablished.Itwouldappearjustastakingthethirdstepearlierthan
thefirst.Wecannotprovideameaningfuldeathwithoutcaringforthemeaningfulnessinlife.
Goodlawsandsoundpoliciescanonlyservetheirpurposeasfunctionsofhumaneculture.
CareinConfuciantermsmeansboth,tocareaboutandforone'sselfandothers.This
circumscribesastrategyofhumaneness.Themeaningofthe"qualityoflife"isessentiallya
personalissue,dependingontheindividual'sstageofmoraldevelopment.Therefore,itcanin
principlenotbeassessedbygeneralcriteria.However,wemayrefertoproceduresthatallowfor
atentativeestimationoftheindividuals'needsandhisrealwill,suchasthroughadvance
directives,otherpositivestatementsofthepatient,oraccountsofthepresumedwill,aprofileof
thecharacterdrawnbycloserelativesandfriends.Asalessonfromourextremelypaternalistic
past,inGermany,ithasbecomelegalpracticetoappealtotherealwillofthepatient,beit
outspokenorassumed,wheneveracaseseemstoincludeacontradictoryconflict.Inotherwords,
thefinaldecisionafteralongandthoroughprocessofconsultationanddeliberationisnotmade
underthepaternalisticprincipleto"actinthe(assumed)bestinterest"ofthepatient,butto"actin
his(mostprobable)realinterest".Ifwecan,wealwayshavetoaskthepatientwhathewants.(In
thespecialcaseofemergencysituations,ifnotimeforconfirmationofthewillisgivenandno
45

Germanyhas,tosomeextent,beensuccessfulindefiningthisconsensusintermsofa"constitutionalpatriotism",
asdifferentfromnationalismorchauvinism.

furtherevidencecanbeprovided,thechieftaskistorestorethepatient'scapacitiesforcompetent
decisionmaking.)AConfucianmightexplainthatthisisasoundpolicy,because,inthemost
extremesituations,physicallifeislessimportantthanmoralselfdetermination.
4Concludingremarks
Itisevidentthatbiomedicalprogressurgesustorevisetraditionalwaystoassessdying.Our
powerstointerfereandtherebytodogoodorwrongtopeoplehaveincreaseddramatically.Our
relatedcapacitiestounderstandandmakesenseoftherelevantethicalimplicationsmustbe
developedinordertoletuscopewiththissituation.Owingtothediversityofindividual
characteristicsofdyingsituationswecanhardlyhopetofindclearethicalguidance,butweneed
tostrengthendecisionmakingcapabilities.Arelatedinitialstepwouldconsistinrealizingand
establishingabetterunderstandingofthemeaningoflifeinthelightofdignifieddeathand
dying.Suchanunderstandingmightbeachievedbestbyunderstandingtheindividualswhowe
refertoassubjects,clients,patients.Weoughttorediscoverthemashumanfellowswhose
processofdyingreflectsourownmoralmaturity.
Ethicseducationinmedicineisanobviouskeytofacilitatethisunderstandingandtheresulting
humanecompetence.Itisalsoselfunderstoodthatthiseducationcannotbedesignedaccording
tothetraditionalmodelsfortrainingandteaching,butmustbesuitabletostimulatecreativityand
individualdecisionmakingability,givingbackpartoftheabsoluteauthorityofteacherstothe
students.Caseorientation,earlyaccesstoclinicalpracticeandroleplaysshouldbepartofsuch
aneducationmethodaswellasplainlanguageandclearethicalconcepts.
However,educationofthiskindshouldbeframedbyeducationofsocietyingeneral.Therelated
sciencesandpolicymakersneedatfirsttobuildasolidempiricalbasisfortheseactivities,
seekingmoreandmoreaccuratefirsthandinformationabouttherealinterestsofterminal
patients.Muchmoreworkshouldbededicatedtounderstandingoftherealsituationsofpatients
whorequestwithdrawaloftreatmentoraskforactiveeuthanasia,asabasisforbuildingan
informedpolicyandpractice.ToknowthatthesepeoplebelongtoaChinese(oranyother)
communityinsomesensedoesnothelpus.Weneedtounderstandwhattheyreallybelieveand

wantindividually,eveniftheresultsconfirmthattheyadhereto"community"basedmorals.In
fact,suchanorientationneedstobeconfirmedandanalyzedempiricallybeforeanynormative
judgementmaytakeplace.
ArecentexamplefrommainlandChinamightbeanencouragingsignalforsomechangeinthe
rightspirit,evenunderunfavourablesocioeconomicconditions.TheDalianmunicipalhas
launchedaresearchprojectinFebruary2001,investigatingthebackgroundofrequestsfor
withdrawaloftreatmentforterminalpatientsreceivinghomecare.Thispilotprojectisconducted
attheFirstDalianMedicalUniversityHospital,directedbytheuniversity'spresidentJiangChao,
andinvolves100patients.Ateamof3doctors,4nursesandadriver,supplementedbypost
doctoralmedicalandpsychologystudentsvisitthepatientsintheirhomesandinquireintotheir
livingconditions,theirfamilysituationandtheirrealwishes.Careandconsultationisofferedas
wellasmediationofsocialworkers'services.ThestudyisfundedbyagrantfromHongKong
businessmanLiJiazheng,amountingtoannually1millionRMBover5years.Itishopedthatthis
willnotonlyprovidemoreadequateunderstandingofthenatureofthereallyneededhelp,but
alsoserveasastartingpointformanysimilarprojectsalloverChina.Itcanbeforseenthatsocial
andmedicalprogrammeswillbenefitsubstantiallyandthatinparticulartheHospicemovement
willgetmomentuminChina.Onthebasisofrichempiricaldatacoveringsrepresentativepartof
ChinesesocietyitwillbemucheasierforChineseethiciststoarriveatasoundadviceforhowto
dealwiththeissueofeuthansia.Theadvicecouldinpartbeassimpleandobviousastheworld
wideevidencesuggests:weoughttobecomemorereasonableinadministeringmorphine
derivativessoastorelievesomeofthechronicalpatients'pain,andweoughttopromote
palliativemedicineasanewmodelforahumanemedicine.
Inmoregeneralterms,weshouldtakeserioustheconcernaboutbioreductionistattitudesand
reductionofpoliticalengagementforthesphereofmerelegalaspectsofbiomedicineaswellas
worryabouttheincreasingdegreeofsocioeconomicpressureonalllevelsofmedicineand
healthcare.Itseemsthatdevelopedcountries,suchasthehomeofmodernhealthcareandsocial
insurancesystemsitself,firstdesignedbyDukevonBismarckinGermany,takeasadleadin
offeringhumanereasoningonthealtarofeconomicrationality.Whenreducedbudgetsandrising
expensesdefinetherealpracticalrangeofmedicalwork,itistimeforustoclarifythepriorities

inclinicaldecisionmaking.Underconditionsofeconomicpressureandsocialfragmentation,
especiallywhengivenalackofthemostbasicmoralorientationinasociety,anydebateabout
euthanasiaisuntimely.Instead,theeconomicpressuresoughttoberelievedfirst,because
individuals'healthandahealthysocietyconstituteamajorresourceforstabilityandprosperity.
Accordingly,attemptstodevelopeacivilconsensus,expressedbyacultureoflawinacivil
societyoughttobefostered.AConfucianviewrecommendsthatweputlessemphasizeon
economics,technologyandmerelaw,butfocusmoreonthehumanefoundationandmissionof
medicine.Economy,technologyandlawareinstrumentalforethics,nothingmoreorlessbut
servantsforhumanity.Therelatedrationalitiesmustnotovercometheprincipalreasonof
humanenessandrighteousness.
Inpracticalsituationsofmedicine,theultimatelyguidingquestionfromanethicalstandpoint
oughttobe:Whichkindofsocietydowereallywishtoliveinandwhatkindoflifedowereally
wishtolive?Ifitisfeasible"tohealsometimestorelieveoftentocomfortalways",as
palliativemedicineinanutshellpromises,thenweoughttoactaccordingly.AConfucian
perspectivemighthelpustoassessanethicalmedicineinlightofthesocialmissionofmedicine.
Wewouldtryourbesttobecomemorehumaneinacknowledgingdyingaspartoflife,andgood
careastheessenceofmedicinealways.