III: CHINA. A. PRE-REPUBLICAN CHINA

The following article has been retained from the first edition, with minor revisions by the original author.

The cultural history of China, as reflected in its literature, shows that for at least two thousand years the Confucian worldview, an ideology concerned with the structure of social life, dominated Chinese society until the collapse of the empire early in the twentieth century. Although less obvious, the philosophy of Taoism exerted a strong influence on Chinese society in the same period. A third major influence in ancient China, that of Buddhism, was introduced from India about the first century c.e. Buddhism exerted its greatest impact on social life and scholarship in China from about the sixth to the early ninth century. Subsequently some of its metaphysical concepts were integrated into Confucianism, its worldly assets were secularized, and its teachings continued mostly on the level of a folk religion. Medical ethics in China, as a consequence of the parallel existence of these three major ways of life, reflects some of the values of all of them.

This article will focus on the history of explicit medical ethics in prerepublican China. By "explicit medical ethics" is meant those norms allegedly present in interactions between medical practitioners and their clientele. The historian has no way of investigating whether norms, as they were expounded by various groups providing health care in China, actually formed the basis of these groups' actions; it is a well-documented fact that explicit ethics are usually far more rigid than the norms actually followed. One can only infer, then, the ethical norms proposed as an appropriate basis of the actual relationship between individual practitioner and patient in prerepublican China. Evidence of appeals to a code of ethics is extant only with respect to a few individuals. One cannot infer from the explicit ethics of a few practitioners the ethics of the whole group. Professional organizations of medical practitioners that might have attempted to enforce a single code of ethics were unknown in prerepublican China.

Historical sources allow for an understanding of the values regarding life and death contained in various ideologies propagated in China. These values, of course, have their immediate bearing on norms regarding the provision of healthcare and medical services. The historical sources further make possible an understanding of the relationship among various practitioner groups and between these groups and the general public. In addition, the historical material forces one to distinguish between traditional explicit medical ethics and modern explicit medical ethics. The former was characteristic of a period in history during which no group of independent practitioners achieved a place in the top ranks of the respective culture's social hierarchy; values dominant in society concerning life and death seem to have been quite stable during this epoch. One purpose of traditional explicit medical ethics, then, may be understood as an attempt by the medical group expounding it to demonstrate its continuous adherence and conformity to fixed, well-defined values.

Modern explicit medical ethics, in contradistinction, results from technologically based advances in Western medicine during recent decades. It represents an attempt to transform values into norms for new situations. The age-old values regarding life and death cannot simply be extended to the consequences of recent developments in healthcare. In contrast to the past, medical scientists in all modern societies work at the forefront of medical progress, and new norms, often representing differing values, have had to be created to cope with situations that formerly were inconceivable, for example, organ transplantation, allocation of scarce primary medical resources, and the maintenance of physiological functions in the terminal patient.

Although statements about medical practice and practitioners are found early in various branches of Chinese literature, the first lengthy and explicit statement on medical ethics of physicians, that of Sun Ssu-miao, appeared in the seventh century. The probable causes for the emergence of such statements at that time demand closer investigation. Medical practice, in whatever form it is carried out, represents a basic necessity for survival not only of the individual but also of the society. Although communities are known that severely restrict, or even totally deny, medical practice, on grounds of the religious beliefs they follow, one otherwise finds an active acceptance in all cultures known so far.

The utilization and the improvement of available primary medical resources (i.e., medical knowledge and skills, drugs and medical technology, medical equipment and facilities) may be viewed as an integral part of most cultures. The problematic variable is which segment of society utilizes and controls these primary medical resources. At the beginning of the Confucian era in China, about two thousand years ago, several groups already participated in the utilization and control of the primary medical resources then available. These resources included preventive and curative therapeutic strategies that derived from separately conceptualized understandings of health and illness. These included a metaphysical perspective concerning the origin of health and illness, which identified the influence of ancestors and demons as responsible for illness, and a naturalistic concept that focused on the relationship between humankind and its physical environment.

The ancestral paradigm is the earliest known conceptual response in China to the experience of illness and early death. It is documented in inscriptions on oracle bones dating back to the Shang dynasty (approximately from the eleventh century b.c.e. on). Even though this perspective lost its dominant position as an explanation of illness and for the design of strategies to prevent or cure illness by the middle of the first millennium b.c.e., it has survived in China until the present. Ancestral healing places living humans in a community with their ancestors, who, although dead, continue to exist. The ancestors guarantee the health of the living as long as the latter adhere to certain norms, and they send individual illness or social catastrophe when they notice a departure from these norms by an individual or society. Prayers and sacrifices by the living may cause the ancestors to withdraw their wrath and restore health or social harmony.

The ancestral paradigm was superseded during the period of the Warring States, in the middle of the first millennium b.c.e., by a belief in the power of demons (i.e., metaphysical entities not directly related to a living human being) to cause illness. Demons, it was assumed, will cause harm to a person regardless of that person's lifestyle; protection is achieved not by adherence to specific moral tenets but by alliances with the forces of stronger metaphysical entities, especially those of sun, moon, the stars, or thunder. Spells and talismans served to demonstrate these alliances and scare away demons in the lesser ranks of the supernatural hierarchy.

When in the early 1970s, a tomb sealed in 167 b.c.e. was unearthed near Changsha in the Chinese province of Hunan, the artifacts found included numerous texts related to healthcare and therapy. These manuscripts offer the earliest available evidence of the development, in ancient China, of a broad gamut of empirical therapeutic strategies, ranging from minor surgery and massage, dietary concerns and recommendations concerning sexual intercourse, to cauterization and, most prominently, elaborate pharmacotherapy. The resort to herbal, animal, and mineral drugs, as well as man-made substances, to cure and prevent illness remained the most important strategy in Chinese medicine until the twentieth century. Most of traditional Chinese medical literature consists of a long series of ever more comprehensive and sophisticated herbals discussing all possible facets of drug lore, and an even greater number of prescription collections, ranging from specialized treatises focusing on one problem to encyclopedic works. Inherent in the use of drugs against illness is an ontological notion that derives from demonologic beliefs. If they did not serve to cure symptoms such as pain or diarrhea, fever, and cough, drugs could kill intruders causing trouble in the organism. At about the time China was united in the second century b.c.e., a further approach to understanding health and illness found its way into medical literature: the ideology of systematic correspondence. Based on a dualistic paradigm of yin-yang and on a scheme of five phases, the entirety of observed phenomena in the human organism and its environment was seen as a system of interrelated, and hence corresponding, items and processes. A person remained healthy as long as he or she was able to live in accordance with the underlying laws of this system; departure resulted in illness. Healthcare on the basis of these ideas was not so much focused on the treatment of manifest diseases as on prevention and on intervention at the earliest signs of change from a perceived status of normalcy. This system of healthcare did not rely on drugs but on an application of needles meant to exert stimuli that serve to regulate imbalances. Nevertheless, the medicine of systematic correspondence also included strong ontological notions. On a more abstract level, if compared with pharmaceutics, the medicine of systematic correspondence harbored as one of its central notions an idea of "evil" entering the organism from the outside or being generated inside. This "evil" could be transmitted inside the body through a complicated system of conduits and network vessels, and had to be located in order to be purged or eliminated.

The theoretical framework and the terminology of the medicine of systematic correspondence closely paralleled the basic tenets and the language of the social theory of Confucianism. Health of the individual body was achieved by the same means as harmony of the social organism, that is, by adherence to specific moral rules. Deviance resulted in illness or social disorder. Just as no enemy was believed to be able to disturb society from within or to enter from outside as long as these rules were upheld, no illness could emerge in the body or be stimulated by an intrusion from the outside as long as an individual followed a specific lifestyle.

For this reason one may call the medicine of systematic correspondence Confucian medicine. Confucian medicine, into which the utilization of drugs was integrated in the twelfth century c.e., was successfully challenged as the officially sanctioned healing system only with the downfall of the imperial society early in the twentieth century.

At the beginning of the Confucian era in the second century b.c.e., medical practice appears to have been in the hands of a variety of practitioners following the principles of the different known medical sciences. In addition there were practitioners, such as a mother treating her child or a neighbor, who possessed and utilized primary medical resources regarded as empirically effective. One has to keep in mind, then, that there was no group with any degree of professionalism practicing medicine in China at that time. In other words, no group of medical practitioners can be said to have been close to having control over all primary medical resources that were available in China almost two thousand years ago.

While it may readily be assumed that the motivation for some people to practice medicine was to help a family member or friend, there is no way to investigate the motives and the actual ethical bases of those persons who chose medicine over any other occupation to earn a living or to exert a social impact. Chinese texts concerned with medical ethics, however, clearly indicate that the desire for control over secondary medical resources (i.e., material and nonmaterial rewards that accrue from medical practice, such as financial wealth or social influence) was a major determinant of the way in which medicine was practiced. At the beginning of the Confucian era, medical practitioners had little control over secondary medical resources. The evaluation of their practice depended on public opinion, that is, on the satisfaction of the laity.

During the following twenty centuries, various groups attempted to reach higher levels of professionalization, that is, to increase the proportion of their control over available primary and secondary medical resources at the expense of the public. One of the important means employed to achieve this end was the appeal to medical ethics (Unschuld, 1979).

Prior to the seventh century c.e., outside of the imperial court in China, no systematic attempt to teach practitioners in medical schools or similar institutions is known. In the first half of the seventh century, the establishment of medical teaching institutions both in the capital of the empire and in the most important provincial cities was decreed. This may be interpreted as an attempt by Confucian decision makers to preserve control over medical resources for the ruling class, the gentry-bureaucracy. The founding of these medical institutions reflects a basic tenet of Confucian ethics, the prevention of the accumulation by any one group in society of control over primary and secondary resources of any kind, which might result in a shift of power and possibly a social crisis or even change.

The underlying principle of many political decisions made in Confucian China was the suppression of emerging groups that had been able to gain control over specific resources. Medical resources were obviously recognized by Confucian decision makers as potential sources of power if accumulated and controlled by specific groups. Several political measures were undertaken to prevent the emergence of socially accepted, influential groups of practitioners. One was to emphasize the unethical character of practicing medicine for a livelihood by pointing out the evil practices employed by those doing so. It was urged that every educated man should possess sufficient medical knowledge to be able to care for his relatives. Another means was to place all extrafamilial care in the hands of civil servant physicians who were representatives of the Confucian class. Thus, it is not surprising that the education of medical officers in the seventh century was designed to supplement the common basic Confucian education. This tendency was further strengthened during later centuries.

The first noteworthy text of medical ethics appeared during the period when the first medical schools began to produce graduates. The author, a noted physician named Sun Ssu-miao (581–682?), was heavily influenced by both Buddhist and Taoist thought. Despite the fact that he was also well versed in Confucian scholarship, he refused on several occasions to accept calls to serve at the court. Sun Ssu-miao may well be called an outstanding representative of free-practicing physicians outside the Confucian group. By "free-practicing physicians" we mean those practitioners who traveled or stayed at home and treated all kinds of patients, in contradistinction to those physicians who had acquired their knowledge solely to assist family members or friends in need, or to serve as civil servants on medical assignments. The fact that Sun Ssu-miao's explicit medical ethics appeared at the same time as the establishment of the medical schools might suggest that it was a well-timed presentation designed to expound to the public the medical ethics of the group he represented.

In his voluminous medical work Ch'ien-chin fang (The Thousand Golden Prescriptions), Sun Ssu-miao chose the heading "On the Absolute Sincerity of Great Physicians" for the chapter devoted to medical ethics. The selection of the term ta-i (great physician) implied on the one hand that Sun Ssu-miao did not intend to speak for all medical practitioners of his time, but only for those whom he regarded as "great." It is a common characteristic of medical professionalization in East and West that at some time or other a few individuals form an elitist group that attempts to distinguish itself from the mass of its colleagues through the demonstration of its exclusive possession of superior primary medical resources. It should also be noted that Sun Ssu-miao's choice of the term ta-i was meant to imply that his group had a status similar to that of the most highly regarded imperial court physicians, or t'ai-i. The Chinese characters for these two terms are closely related in structure and meaning. Considering the low-ranking social position officially accorded to free-practicing physicians in Confucian China, the use of this title represented a bold demand for the social elevation of their elitist group of practitioners.

Sun Ssu-miao's treatise was meant to serve two purposes. First, by laying stress on the evaluation of treatment procedures rather than on the outcome of treatments, as was common at the time, he provided a measure of protection for the practitioner in instances where prognosis was unfavorable or outcome unsuccessful. The second purpose was to imply that his "great physicians" should be trusted more than was usually the case. As an introduction to his explicit medical ethics, Sun Ssu-miao provided his readers with a framework of the healing system he and other great physicians allegedly adhered to. It was based on the same theories and concepts that underlay the Confucian-supported medicine of systematic correspondence. Other writings of Sun Ssu-miao reveal, though, that he also favored demonic medicine, a healing system persistently repudiated by Confucians. In his explicit medical ethics, Sun Ssu-miao chose not to mention this aspect of his medical beliefs. He laid a great emphasis on thorough training for those who wish to practice medicine successfully and thus aspire to the title "great physician." Such tactics were important at that time, because the medical practitioners approved for governmental service were being institutionally trained in official medicine and were thus calling into question the background of free-practicing physicians.

It is characteristic of explicit medical ethics, as propounded by individuals who strive for a higher level of professionalism for their group, to incorporate the basic social values of the dominant groups in society. Therefore, Sun Ssu-miao's explicit ethics frequently stresses certain values central to Confucian and Buddhist thought, such as jen (humane benevolence) and tz'u (compassion). Furthermore, certain maxims are emphasized, for example, the obligation to maintain life and to treat human beings regardless of their status, origin, appearance, or the kind of disease they have.

Sun Ssu-miao seems to have grasped some important psychological aspects of the patient-physician relationship. He apparently realized that in order to gain the confidence of patients, and thus unlimited access to secondary medical resources, the physician must appear neutral and above normal human emotions, uncorrupted by even the most tempting worldly rewards.

One recognizes as well Sun Ssu-miao's sense of belonging to the larger group of medical practitioners when he points out the inappropriateness of abusing physician-colleagues in public. The detrimental effects of such shortsighted behavior, directed toward individual gain, have been recognized by the best minds of the East and West as impeding group professionalization. Thus, from the very beginning of explicit ethics in medicine, elements were incorporated that seem to have little to do with the actual performance of medical treatment and may be regarded as beneficial solely to the medical practitioners.

Finally, Sun Ssu-miao touched on the problem of remuneration. Greed seems to have been one of the gravest complaints raised by the public against practicing physicians. Many statements, promulgated by Confucian interests, expressed this view. If the public were to be convinced that at least the "great physicians" did not intend to cheat their patients, then another system of equitable remuneration had to be elaborated. Sun Ssu-miao referred to a saying of Lao-tzu (604–? b.c.e.), the founder of Taoism, to the effect that good deeds would certainly be rewarded by fellow humans and that evil practices would induce retaliation from the spirits. Thus Sun Ssu-miao approached both the Confucian ideal of virtue as its own reward in the continuation of one's name or fame in posterity and the Buddhist idea of reward or retaliation through supernatural forces, in either this or a later life (if not in another world).

The history of explicit medical ethics in China in the centuries following Sun Ssu-miao very much resembles a debate among three main groups. These were the free-practicing physicians (including Buddhists, Taoists, and others) in whose interest Sun Ssu-miao had spoken, the orthodox Confucians, and a group within Confucianism consisting of ordinary scholars (and at least part-time medical officials) who practiced medicine as a paid profession.

About 150 years after Sun Ssu-miao had published his ethics, Lu Chih (754–805), a well-known scholar from the top ranks of the Confucian bureaucratic hierarchy, made some statements on medical ethics that might be regarded as a direct answer to Sun Ssu-miao. He elaborated on the idea that medical knowledge, and the ability to practice medicine, must be regarded as open to everyone. The implication is that practitioners who specialized in medicine would become superfluous. Lu Chih also chastised those who practiced medicine for living in a manner characterized by greed and evil, and noted that they did so without suffering any kind of retaliation. This observation put Sun Ssu-miao's system of retribution in question. However, Lu Chih also pointed out that those who had practiced medicine without undue concern for material gain but, rather, as an obvious consequence of their concern for humanity had been rewarded one or two generations later, through the happiness and prosperity enjoyed by their children and grandchildren. Lu Chih closed his remarks with an open critique of Taoist and magical practitioners, among whom Confucian historians counted Sun Ssu-miao. At the beginning of the thirteenth century a Confucian scholar-physician named Chang Kao published twelve short stories concerning medical ethics. While decrying the non-Confucian practitioners as "common physicians," Chang Kao recognized the need to allay the fears of orthodox Confucians, who were always suspicious of attempts to gain control over specialized resources.

In his stories, entitled "Retribution for Medical Services," Chang Kao conspicuously resorted to Buddhist concepts of reward and retaliation by forces of another world. These stories center on four major dimensions of medical ethics: greed vs. altruism; exploitation of sexual opportunities; conscientiousness in medical practice; and the problem of abortion.

The last is of special interest because other medical authors showed little concern over the practice of abortion. Relevant prescriptions are frequently provided in major collections. During the reign of the Mongol Yuan dynasty (1260–1367) an official decree prohibited unqualified women from performing abortions. Chang Kao's exceptional handling of this problem was certainly based on his adherence to Buddhist principles. The structure of his entire message seems highly psychological. In the first story, Chang Kao extolled the use of primary medical resources as an appropriate way to gain merit by giving assistance to others. In the second story, he recounted an example of very laudable behavior of a Confucian scholar-physician designed to reinforce confidence in that group. The third through the tenth stories portrayed the decay of morals and depicted examples of many "evil" practices (among them abortion) performed by physicians and others who openly practiced for money with the ulterior motive of cheating the patients. All of these characters received their proper punishment through the actions of gods, spirits, or demons. The last two stories again helped to create confidence in the group to which Chang Kao belonged.

About one century later Ko Ch'ien-sun (fl. 1348), a free-practicing physician, made an ethical statement that was somewhat different from others. In contrast to Confucian ethics, which stressed the study of literature, he emphasized the necessity of gathering clinical knowledge at the bedside as a prerequisite of the well-versed practitioner. Ko Ch'ien-sun departed even farther from official medicine in stating that the origin of his miraculously effective prescriptions rested with a supernatural being who had handed them to him and they were not, in fact, derived from concepts and theories of nature underlying Confucian medicine. Ko Ch'iensun is mentioned here as only one example of the vast heterogeneity often overlooked in Chinese traditional medicine.

Most interesting in Ko Ch'ien-sun's statements was the emphasis placed on the outcome of his own practice and the paucity of details concerning his treatment procedure. His reversion to outcome evaluation and other such evidence reminds one that ethical statements found in the literature cannot be taken as representative of the medical group as a whole. It must be assumed that they represent the views of a progressive minority, where "progressive" means an intention to increase professional control over the resources available in society.

In 1522, Yü Pien wrote an interesting modification of the orthodox Confucian claim that everyone ought to possess medical knowledge. Speaking for the group of practicing physicians, he stated that not everyone needed to have medical abilities but that those who called on "common physicians" for assistance could not be regarded as showing sufficient filial piety, and added that medical knowledge was imperative for those who wished to assist their relatives. This very cautious, almost paradoxical, statement may be interpreted as an attempt to legitimize free-practicing Confucian physicians and at the same time to discourage the public from resorting to practitioners outside the Confucian sphere of influence.

New dimensions were incorporated into medical ethics by Kung Hsin, who lived around 1580, and by his son Kung T'ing-hsien (fl. 1625), both of whom had been imperial court physicians. Kung Hsin explicitly rejected patient solicitation, a practice common in China in his time and later. Patient solicitation implies that a particular physician may be better than at least some of his peers. The awareness of differences in standards of performance necessarily leads to public distrust of the group as a whole and, therefore, constitutes an obstacle to further professionalism. Only where the notion predominates that all members of the practitioner group are alike in their standards of performance will there be confidence among potential clientele.

Kung T'ing-hsien, the son, wrote short treatises entitled "Ten Maxims for Physicians" and "Ten Maxims for Patients." In the first of these he underlined the mastery of Confucian knowledge as a prerequisite for medical practice, a point his father had not explicitly mentioned. In his ethical prescriptions for patients, Kung T'ing-hsien demanded that they resort only to "enlightened physicians," willingly take their medicines, start treatment early, avoid sexual intercourse, refrain from belief in heterodox medical resources (i.e., not Confucian-sanctioned), and not worry over medical expenditures. This last point was underscored with the familiar rhetorical question "I ask you what is more valuable to you: your life or your property?"

Ch'en Shih-kung (fl. 1605) also belonged to the free-practicing group of Confucian physicians. He was the first known Chinese physician to suggest that such persons as prostitutes could be treated without risking defamation. Ch'en Shih-kung also offered his colleagues what may be the first investment counsel for physicians when he advised them to invest excess capital in real estate and not to spend money in unethical places like wine houses. His profound sense of belonging to a larger group led Ch'en Shih-kung to urge his peers not only to avoid open criticism of each other but also actively to display benevolent loyalty among themselves despite differences in training and opinion. Finally, he elaborated upon the prohibition of patient solicitation. He counseled that it was inappropriate for physicians to give extravagant presents or costly dinner invitations to other people. His remarks represent a most pragmatic view of medical ethics (Lee). The progress in professionalization that becomes evident through the claims made in explicit medical ethics reached its peak at the end of the era of imperial China. Hsü Yen-tso (fl. 1895), the last author to be cited in this regard, followed the trend when he offered advice to both physicians and patients. He held that in order for a practitioner to maintain a proper level of morality, he was obliged to treat anyone who requested help, regardless of social or financial status; to provide conscientious treatments; to show extreme sincerity; and to respond to any call as soon as possible. In a statement regarding the patient-physician relationship he reminded his colleagues that patients await the arrival of the practitioner as if he were a supernatural being, like the Buddha himself. From this perspective it is not surprising that he asked patients to place themselves entirely in the hands of the practitioners. He demanded that patients have no secrets; that they bind themselves permanently to the physician, not only tempo-rarily in case of an emergency; and that they be isolated from their normal social environment during treatment. The last stricture was possibly meant to prevent discussion of the case and the treatment provided, and had the effect of precluding criticism or interference from outsiders. Thus, at the end of the era of Confucianism, control by a specialized group over medical resources had progressed to a stage incompatible with the original Confucian maxims.

paul u. unschuld (1995)

bibliography revised

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