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Government of the Russian Federation

National Research University Higher School of Economics

Faculty of World Economy and International Affairs

Educational Programme

�Socio-Economic and Political Development of Modern Asia"

MASTER'S THESIS

Bioethics with Chinese characteristics: cultural contexts and modern trends

Student - Vera Karateeva

Reviewer - Scientific Advisor Andrey Vinogradov

Moscow, 2020

Table of Contents

Introduction

Chapter 1. The Basics of Bioethics: General Methods and Concepts

1.1 Methods in Bioethics

1.2 The Application of Principles in Bioethics

1.3 Main Subjects of Bioethics

1.4 Alternative Approaches in Bioethics

Chapter 2. Chinese Bioethics as a Discipline. Sources, Theories and Reconstruction Processes

2.1 Brief History of Bioethics in China

2.2 Chinese Bioethics Dictionary: some illustrative examples

2.3 Construction of Chinese Bioethics

2.4 Criticism of Individualism, Autonomy and Human rights

2.5 Comparison of Bioethical Problems: China and the West

Chapter 3. Chinese Bioethics in Practice: Legal Framework

and Public Opinion

3.1 Laws and Regulations in the Field of Chinese Bioethics

3.2 Public Opinion: Arguments Pro et Contra Biotechnologies

3.3 Major Findings and Conclusions

Bibliography

Introduction

�The shock of confronting the unfamiliar often stimulates a new, creative vision of the familiar; at the very least, it can generate a heightened self-awareness among participants in a discipline of discourse,� writes Robert Campany, a researcher of Chinese religions in Indiana University Campany, Robert F. (2010) �Taoist Bioethics In the Final Age,� p. 68. In Camenisch, P.F., Young, K.K. (eds.) Religious Methods and Resources in Bioethics. Springer. . That is what, I suggest, contemporary bioethics lacks the most because the field's scholars often deal with material from their own culture and pay insufficient attention to comparative study.

What is bioethics? New technologies and methods give us unprecedented possibilities in terms of health improving, reproductive medicine, and gene therapy, along with making us face new challenges and dilemmas. A discipline concerning the problems of these spheres is called bioethics. It considers such subjects as organ transplantation, biobanking, euthanasia, therapeutic cloning, surrogacy, human genome editing, etc. According to Encyclopaedia Britannica, bioethics is a branch of applied ethics studying the philosophical, social, and legal issues arising in medicine and the life sciences �Bioethics,� Encyclopaedia Britannica. URL: [https://www.britannica.com/topic/bioethics].. Interdisciplinary by nature, bioethics use methods and content of biology, healthcare, ethics, cultural studies, and sometimes theology. Apart from academic researchers with their unengaged interest, bioethical issues concern many journalists, religious people, secular social activists, and governmental actors, who are shaping their own particular �bioethics� apart from medics and researchers.

There are different positions on how universal or local bioethics can be. The most recent works on the subject published in the 2000s-2010s usually do not put any blatant universalist statements that the whole world must rely on the same set of established principles. Modern bioethics mostly believes that different societies have different values, body perceptions, theories of individual and collective, and understanding of actors in bioethical issues. Some methods, like, for example, the reflective equilibrium method, involve many premises and opinions in search of a compromise. Or, the feminist approach, which often pays a lot of attention to the social and other contexts of particular cases. These two we will discuss further in chapter I. However, researchers ask whether local bioethics can be relevant. For example, Gerhold K. Becker, German philosopher and founder of Hong Kong's first Center for Applied Ethics, doubts the viability of Confucian bioethics in today's globalized and multipolar world. Thus, he quotes Ci Jiwei, Professor of the Department of Philosophy School of Humanities, Faculty of Arts University of Hong Kong, who writes: �... those who have absorbed the Confucian concept of human relations would be socially and ethically at sea if they were to enter into relations with strangers, where the conjunction of hierarchical-reciprocal relations and kinship ties simply does not exist. Becker, G. (2006) �Chinese Ethics and Human Cloning: A View from Hong Kong,� p. 116. In Roetz, H. (ed.) Cross-Cultural Issues in Bioethics: The Example of Human Cloning. Brill. � Given the fact that various cultures have different concepts of the human body, which is bioethics' essential subject and which have many implications for the overall culture, we have to recognize the existence of specifically Chinese bioethics as something different from conventionally Western bioethics. Moreover, China is putting significant efforts to shape it, and in many ways - to counter the Western ideas and principles. Since there are quite a few works dedicated to this problem, I would like to make it the study's central question - how exactly does Chinese bioethics exist.

In the West, there are many exclusive works dedicated to the genesis of contemporary bioethical principles, legal framework, related institutions, and the most recent tendencies in bioethical thought. In Asia, these issues, for the most part, remain uncovered. For several reasons, this situation is problematic. According to Heiner Roetz, �modern biotechnology concerning human medicine, at least in some aspects - e.g., cloning, germline engineering, and genetic enhancement - might well in the long run affect not only the destiny of individuals, but that of human biology itself and ultimately the evolutionary future of humankind.� Roetz, H. (2006) (ed.) Cross-Cultural Issues in Bioethics. The Example of Human Cloning, p. x. He also emphasizes that the new processes in bioethics and biotechnology are global so that their state in one country inevitably affects others. That makes considering China even more critical because of the peculiarities of its mentality, society, and politics, which create a unique picture in the field. Besides, the country goes in the vanguard of technology development and strives to be at least one of the world leaders in biotechnologies.

A scholar S�ren Holm underlines political component in bioethics, as it �analyses policy decisions and thereby has an interface with political philosophy.� Bioethicists �often give unsolicited policy advice, but many also have more official roles on various kinds of ethics committees advising political decision-makers.� Holm, S. (2007) �Policy Making in Pluralistic Societies,� p. 153. In The Oxford Handbook of Bioethics. Oxford University Press.

I would like to put forward several reasons why China deserves more attention concerning this particular field:

- China is extremely active in high technologies development, including biotechnologies/innovative medicine, and makes crucial discoveries in the field;

- Since the presumption that Chinese culture differs significantly from the Western ones, local bioethics can have differences, too;

- Comparative analysis of two or more cultures of bioethics can bring priceless conclusion and profound understanding of how it is constructed, from what it depends, and what awaits it in the future;

- Bioethics can serve as a paradigmatic illustration of China's social politics and the country's changing position in the modern world. In addition, Chinese bioethics is one of the subjects of active criticism coming from the United States and, more broadly, Western society. In this thesis, I consider media materials that prove this fact. Thus, the topic of our study can tell a lot about the international relations of China.

Taking into account the lack of publications dedicated to bioethics in China, this paper covers a wide range of issues, trying to provide a theoretical apparatus and general overview of the topic. As Michael Barr and Joy Yueyue Zhang suggest in their article, with the grandiose rise of China in the early 21st century, the world was eager to know if it will adhere to the global �status quo� and play by its rules, or will try to reinvent the international system Barr, M., Zhang, JY. (2010) �Bioethics and Biosecurity Education in China: Rise of a Scientific Superpower,� p. 116. In Education and Ethics in the Life Sciences: Strengthening the Prohibition of Biological Weapons. Australian National University Press. . We will try to assess whether this is possible in the field of bioethics. Thus, my main research questions are:

- Does Chinese bioethics differ from the Western one, and if so, how exactly? What are their common grounds? Can they coexist?

- What are philosophical and religious (Confucian, Taoist, and Buddhist) backgrounds of Chinese bioethics?

- How the legal framework for bioethical research in China looks like, and how the government implements these laws and prescriptions?

- How various groups of Chinese society evaluate bioethical issues?

Given this set of questions, our research goals are:

(1) Indicate the features of Chinese bioethics and to trace their formation through Confucian, Taoist, Marxist, and other influences; to study and describe its cultural, historical and political backgrounds;

(2) To analyze similarities and differences with Western bioethics in a number of particular issues such as euthanasia, organ transplantation, reproductive technologies, cloning, etc.

3) To find out how bioethics is applied in contemporary China.

The paper's hypothesis is that Chinese bioethics presents a multi-composite compound of intrinsic cultural features, �reinvented� Confucian and Taoist cultures, politically determined principles and specificity of operation of biotechnology regulatory system.

On the one hand, according to mainstream ideological trend of PRC, Chinese bioethics �should� demonstrate that it could introduce authentic version of the discipline and incorporate in in all richness of Chinese ethical and cultural experience. On the other hand, it should not violate global conventions to avoid jeopardizing the country's international reputation. But the first imperative is more suggestive: as I will try to show, the Chinese consider it their special mission to create a competing and even confrontation model with the West in bioethics.

The paper consists of three chapters.

The first chapter aims to introduce in bioethics in general. I will discuss history and definitions of the discipline, its subjects, tools, and principles, mainstream and alternative approaches, international conventions, and dilemmas.

The second chapter deals with historical, cultural, and religious background of bioethics in China. It presents a history of Chinese bioethics as a research field, linguistic analysis of some particular Chinese terms and expressions, the analysis of works of Chinese scholars dedicated to construction of Confucian and Taoist bioethics, and popular Chinese textbook on biomedical ethics.

The third chapter studies the practical implementation of bioethics in contemporary China. I will observe respective laws and regulations, as well as the specificity of its application. The chapter presents a public opinion study and some particular case studies based on collected articles, news, and interviews. That is made to understand the attitude of various social groups in China to relevant bioethical issues.

The elaboration of the topic was carried out using a number of methods. A method that best matches the structure and main idea of the work is the cross-cultural analysis. It involves collecting a lot of data presented by different cultures (Chinese bioethics and �Western� We use parentheses because there is no single Western bioethics, as well as there is no single �West�. However, bioethics originated in the US and its mainstream can be attributed to it and European countries. Thus, we let ourselves to use this simplification in our analysis. bioethics in our case) and comparing them in order to find common features and differences. As a part of it, I also used comparative method. In studying �manifestos� of Chinese bioethics and analyzing its construction processes I used textual analysis. I have also observed a number of laws and regulations in Chinese, so the work includes document analysis. In the second chapter the author uses linguistic analysis in studying Chinese characters, terms and expressions. I have discovered that some of the terms have such overtones and connotations that enable them to serve as imperatives and give answers to some bioethical questions; and a number of terms have different context of use comparing to their equivalents in English or Russian languages, which also gives a different vision of the same problems. Finally, the last part of the chapter III represents three case studies: I have observed incidents in the framework of Chinese bioethics and their public reception among the scientists, journalists and ordinary people using media and social media (popular Chinese microblogging website Weibo) materials. bioethics cultural china

Literature Review

The theme of given thesis is rather wide and includes a number of sub-topics, therefore the sources are also very diverse. The characteristic feature of the source design is that the author uses scholarship texts written by Chinese bioethicists as primary sources, not secondary ones, that requires some clarification. Within the context of Chinese bioethics they could have been classified as secondary, being observed as analytic literature. But this work concentrates on comparative bioethics and studies its Chinese version �from the outside�. That is why it is important for our purposes to evaluate them in the most critical way possible, understand the imperatives and backgrounds of statements contained in them, which are in reality highly specific.

Sources classification reflects the structure of the thesis. The first chapter is dedicated to �general bioethics�: it was important for our purposes to observe it and create critical apparatus for the further study of Chinese bioethics. Thus, we shortly described a history of bioethics as a discipline from its appearance in the US in 1970s, its key subjects, schools, methods, principles, tools, problems and dilemmas on the basis of several books, documents and news articles (both primary and secondary sources, for example: The Oxford Handbook of Bioethics, 2007; Belmont Report, 1978; Convention on Human Rights and Biomedicine, 1997; Beauchamp, T., Childress, J. Principles of Biomedical Ethics, 2012; Veatch, Robert M., Guidry-Grimes, Laura K. The Basics of Bioethics, 2019; and many others). In spite of the fact that bioethical thought is rather diverse, the author allowed herself to state the division between �mainstream� bioethics (represented by the compendium of authoritative scholar works) and �alternative� one that consists of several approaches. In its turn, we divide alternative approaches in bioethics to secular ones and religious ones. Alternative secular bioethics includes feminist and narrative approaches, while Catholic, Protestant, Orthodox Christian denominations, and Islam represent alternative religious approaches. These religions were chosen as those that represent the Western tradition (Islam find itself here because of its Abrahamic origin). At the same time, my tasks have not supposed me to conduct analysis of all such religions: only vivid examples were needed. As a result, I have found a number of parallels with Chinese bioethics, both in reasoning and conclusions. In this last �religious� section of the chapter the sources included such documents as Fundamentals of the social concept of the Russian Orthodox Church (2008) and a number of Catholic documents (encyclicas, papal declarations, etc.).

Second chapter proceeds to Chinese bioethics: to its theoretical dimension, in particular. I have studied a number of collections of articles that can be considered manifestos of Chinese bioethics: they show the processes of constructing this discipline with Chinese characteristics. It is primarily the book �Bioethics: Asian Perspectives. A quest for moral diversity� (2004) edited by prominent scholar Qiu Renzong; �Confucian Bioethics� edited by Fan Ruiping (2002); and �Cross-Cultural Issues in Bioethics. The Example of Human Cloning� edited by Robert Fisher and Margaret S�nser Breen. Another valuable source in my list is a popular Chinese textbook, Shi Weixing's �Biomedical Ethics� (Shengwu yixue lunli xue) published in 2010.

The articles in the collection titled Bioethics: Asian Perspectives Qiu, R. (2004) (ed.) Bioethics: Asian Perspectives. Springer. focus on many diverse topics, but all of them agree on the main conclusions and messages. This collective work's character is more imperative and political, than scientific, but, however, it remains within the framework of academic knowledge. For this reason, the book is especially important. It reflects the point of view of reputable scholars, has an influence on other papers in the field and can be taken into account in the decision-making process on various bioethical issues. Its principal notions are that (1) universal bioethics does not and cannot exist, (2) Asia should develop its unique bioethics, based on its cultural heritage; (3) Confucianism and Taoism have great potential as a source of solving bioethical issues, (4) in crucial matters, Chinese thought differs significantly from the Western perspective. Here are some key factors of this difference:

- Family relations as a subject of the greatest concern.

- Different concepts of personhood: individualism and higher-brain functions (West) vs psychosomatic unity and social/relational being (Asia); self-actualization per se (West) vs fulfilling social responsibility, incorporation between the self and the other (Asia).

- For Chinese culture, Western ethics and bioethics lack the relations between humans and Nature.

- There is no concept of human rights in Confucianism, and individual rights often are not taken seriously.

- It is underlined that the patient must seriously consider non-medical factors such as the extent of the financial burden on him/herself and others. In Western books on bioethics it is not prescribed as an imperative. But it should be another point of view, too: Confucian culture promotes care for the weak and ill, so a burden of any kind definitely can not be an argument in withdrawal of the treatment.

Being unable to critically evaluate all the articles in this section of the paper, I would like to name two main types of criticism. First, despite that this collection is presented as an academic piece, it has an imperative dimension and bears a powerful value message. Second, criticizing Western bioethics, Chinese scholars, for the most part, consider only its "skeleton," or basic assumptions. Thus, they do not take into account neither the variety of approaches and schools nor the internal criticism in the field elaborated since the discipline's very appearance.

The other work, along with many others, belongs to a fundamental enterprise for the reconstruction of Confucianism in modern China. These processes are being performed in education, politics and many other fields. The major difficulty of the task is that Confucius and many other important Confucian thinkers said nothing or almost nothing about the human body, health, birth, death, and the topics alike. The ways of how Chinese bioethics solves this problem are similar to the methods of how the religious people or professional theologians interpret holy scriptures. They interpret some statements allegorically, or, in other cases, they refer to the continuity of the Confucian world, where the material is bound with spiritual, and the microcosm is identical to the macrocosm. According to this logic, they argue that everything that Confucius says about human relations, governing, and morality is related to health. Curiously, the opposite way of interpretation is also popular. For example, Jing-Bao Nie's article titled �Human Drugs� in Chinese Medicine and the Confucian View: An Interpretative Study proposes to interpret the practices of traditional Chinese medicine ethically. However, the approach and criticism of this collection are not hermeneutical: its authors do not seek to understand what exactly their sources say but offer a way of interpreting them, which they choose according to their political and educational preferences.

Shi Weixing's Biomedical Ethics textbook is used by medical and biology students, which make it valuable enough for our study. The title of the textbook does not feature neither �Chinese� nor �Asian� keywords, and yet it is significantly different from Western bioethics textbooks. On the one hand, it describes the foundations of bioethics, discussing the main issues and approaches of this initially Western discipline. On the other hand, bioethics is a practical field, and the manual observes the realities of Chinese life, making it a valuable cultural and anthropological source as well. Besides, the analysis of fundamental bioethical issues, as presented in the collection, differs from the Western one. It considers some questions that are not raised in American and European handbooks and omits others that are important to the formers. The second chapter of the paper is dedicated mostly to comparing the key bioethical topics (reproductive technology, organ transplantation, euthanasia, etc.) in Western and Chinese discourses.

The third chapter examines practical applications of Chinese bioethics. First section discovers main laws and regulations that determine the legal framework of different bioethical topics. The list of sources includes Marriage Law of People's Republic of China (��?�l�����a�������@); Ethical guidelines for human embryonic stem cell research (�l��ي�?�E����?���w?��?) ; Regulations on Human Organ Transplantation (�l�̊튯�ڐA���) and other laws and regulations, as well as reports on China's Ethical Review System and news reports (for example - The Central Provincial Reform Commission meeting reviewed and approved the National Science and Technology Ethics Committee Formation Plan (���ƉȋZ?����?��?������).

The last part of the research is dedicated to the high-profile bioethical cases in China and their public reception. First of all, it is the case of He Jiankui's case of editing of human embryos' DNA with reproductive purposes. For example, it is an article in Life Times Magazine (����ʱ��) �Why do we oppose "gene editing of babies"? The reality can me more frightening than we used to think�. The release contains the interviews with experts and scientists commenting the incident. What is interesting in this and similar articles, is a kind of dualistic and double-edged massage. On one hand, Chinese scientists condemn the experiment of He Jiankui, and on another they do not exclude the future possibility of gene editing and human enhancement. We can observe the same situation in Chinese books on bioethics: for example, Shi Weixing say that brain's transplantation will rise tremendously complicated social questions, but still it can resolve medical problems and can come to practice in the foreseeable future. In addition to journalistic articles, the author uses the posts and comments on the Weibo social network as primary sources.

Chapter 1. The Basics of Bioethics: General Methods and Concepts

In the first chapter of the paper, I will try to give a systematic overview of bioethics as a discipline. Concerning the terms, it is noteworthy that I will use both �general� and �Western bioethics� while acknowledging that discipline's approaches can differ from country to country, from one social group to another, and from one bioethics school to another. We still say �Western bioethics� as it emerged in the West, namely in the US, and it is possible to determine key issues and structures that make possible further development of bioethical knowledge. We can also put ourselves and form a view of it by studying authoritative tutorials, collections of articles on bioethics, and well-known cases, just as if we were Chinese scholars who study to construct their own bioethics in the future.

By the course of this research, I will briefly outline the main milestones in the history of the discipline, describe the basic concepts of bioethics, and analyze how they turn into specific work tools. The chapter will provide examples of complex cases and dilemmas in bioethics faces. At the end of the section, I will talk about �alternative� bioethical approaches: secular (narrative and feminist) and that offered by various Christian denominations and Islam. All this will help us to create analytical tools to study Chinese bioethics in the second chapter.

Bioethics originates from medical ethics, the history of which goes back to ancient Greece, at least to the times of the Hippocratic Corpus (5-4 centuries BC). If the subject matter of medical ethics is primarily the doctor-patient relationship, bioethics considers more extensive range of issues related to human life (especially new topics appearing due to the development of medical biotechnologies), environmental issues, public health, and medical policy. On the other hand, if we define bioethics from the ethic's side, we should refer to American philosopher James F. Childress, whose works in bioethics are very authoritative. He says that the early bioethics of the 1970s were often understood as �applied ethics,� and later, in 1990s, this definition was discarded in favor of the `practical ethics' Childress, James F. (2009) �Methods in Bioethics,� p. 15. In The Oxford Handbook of Bioethics. Oxford University Press. .

The first institute of bioethics appeared in the US in the 1960s, the first Encyclopedia of Bioethics Steinbock, B. (2009) The Oxford Handbook of Bioethics, p. 3. was published there in 1978. For my research, it is vital that, according to the editor of The Oxford Handbook of Bioethics, religion, or, more specifically, theology, played a significant role in the formation of bioethics. That is not surprising that these theologians were mainly Protestants because American most common Christian denominations are Protestant. Among the most influential figures in the initial formation of the discipline was an Episcopal minister Joseph Fletcher, known as an enthusiastic proponent of potential benefits of abortion, euthanasia, eugenics, and cloning, a Methodist minister Paul Ramsey; a somewhat exception is a Jesuit moral theologian Richard McCormick. They were joined by some philosophers soon. From the very beginning, bioethics was a kind of a structured melting pot of ideas and convictions, both secular and religious.

As B. Steinbock states, �the central issues in bioethics were research with human subjects, genetics, organ transplantation, death and dying, and reproduction� Ibid., p. 4.. In the context of fast biotechnological progress, bioethics seeks to understand, which of scientific achievements can be fearlessly applied, which should be applied cautiously, and which new possibilities should better stay possibilities. Also, it tries to provide a methodology to balance conflicting principles in complex issues.

There are two general approaches to resolving bioethical questions:

Principlism: we act according to principles consistent with our value system. This approach is dominant in Western countries. There, basic principles include beneficence, non-maleficence, autonomy, justice, veracity, and fidelity.

Consequentialism: we may judge an action not by itself, as good or bad, right or wrong, but only by its ends and effects, which must comply with the needs of the utility. This approach is more common in China. For example, Chinese bioethicists can consider the one-child policy bad in principle, but good in the outcomes, and therefore justified.

Now let us analyze bioethics' methodology in more detail.

1.1 Methods in Bioethics

One of the most challenging issues in bioethics is methods, which are based on the set of values, axioms, and procedures that allow us to understand how to manage the matter. Much depends on where do we find our fundamental assumptions. For example, Catholic or Orthodox Christians count on the Holy Scripture and Tradition, Muslim scholars focus on Quran and Hadith, and Western bioethics is close to some particular schools of ethical philosophy like consequentialism and utilitarianism, or use philosophical systems of philosophers like Immanuel Kant, John Stuart Mill, Isaiah Berlin, etc. Thus, before considering specifically Chinese bioethics, we would like to address some traditional ways of dealing with the ethics of human life, death, and health.

In studying bioethical methods, we will primarily rely on James Childress' article for The Oxford Handbook of Bioethics Childress, James F. (2009) �Methods in Bioethics,� pp. 15-45.. He distinguishes principles and rules; the former are more abstract expressions of moral values to guide our points and conclusions, and rules are specific laws that governments, doctors, and ordinary people have to follow. So a particular bioethical approach is a combination of principles and, sometimes, rules. The above-mentioned consequentialist approach can be used in conjunction with using principles or chosen as a central tool. For example, a traditional medical point that �if it is needed, a surgeon must inflict pain and amputate a part of the patient's body to save their life� is essentially consequentialist: we judge an action (like inflicting pain) by its results. What is essential here is that such an approach of utility cannot operate without articulating values like saving a person's life at any cost, even if he or she wants to give up living. Other values include happiness, pleasure, and individual preferences that do not hurt others. Within the general consequentialist/utilitarian framework, there are several more nuanced approaches like act-consequentialist and rule-consequentialist. Still, all of them agree on the principle of �producing the greatest good for the greatest number.�

There is also the approach dubbed deontological since it focuses on the moral nature of particular actions rather than on their consequences and intentions. Recalling Immanuel Kant's �categorical imperative,� sometimes it is also labeled as �Kantian,� which is not entirely correct. Though often applied in religious traditions such as Christianity, Islam, or Buddhism, it is primarily secular and embraces secular with it's �natural law,� reason, and conscience. Deontological values include the sanctity of human life, avoidance of killing, respect for people's autonomy, and fidelity to promises. In most cases, the deontological approach means the rejection of euthanasia or assisted suicide. However, its critics point out that some of its most fundamental values, like the sanctity of life and autonomy, are hardly compatible with each other.

In practice, bioethical decisions often include both consequentialist and deontologist components, being based on a combination of principles. There is no generally accepted consensus on a strict set of principles one must adhere to. The document, shortly called The Belmont Report, issued by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research in 1978, identifies �three principles, or general prescriptive judgments, that are relevant to research involving human subjects.� �The Belmont Report. Ethical Principles and Guidelines for the Protection of Human Subjects of Research,� The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, p. 1. URL: [https://videocast.nih.gov/pdf/ohrp_belmont_report.pdf]. These three are (1) respect for persons, including respect for individual choices and protection for non-autonomous persons, (2) beneficence, and (3) justice. This text is mostly opposed to the Chinese approach, as we will see later. Thus, it defines the medical practice as �interventions that are designed solely to enhance the well-being of an individual patient or client,� while for Chinese, the community of people with its needs and interests should be a beneficiary of medical practice.

Many other Western scholars offer a similar to The Belmont Report's list of principles. In their book Principles of Biomedical Ethics, Tom Beauchamp and James Childress list four basic principles, which are respect for autonomy, non-maleficence, beneficence, and justice, and several secondary ones, including veracity, fidelity, privacy, and confidentiality Beauchamp, T., Childress, J. (2012) Principles of Biomedical Ethics, 7th ed. Oxford University Press. . Robert Veatch, professor of medical ethics at Kennedy Institute of Ethics, name beneficence, contract-keeping, autonomy, honesty, avoiding killing, and justice Veatch, R.M. (1981) A Theory of Medical Ethics. NY: Basic Books. . Although any such lists vary in detail, they all reflect similar underlying presumptions and agree on the most critical matters.

There is an inherent problem with the application of principles since often they cannot be implemented directly and do not give a specific solution to uncommon situations. Childress points out three modes of connection: (1) deductive application, (2) balancing that depends on intuitive weighing, and (3) specification, which proceeds by �qualitatively tailoring our norms to cases.� Childress, James F. (2009) �Methods in Bioethics,� p. 24. Since these formulas are at best vague, each case requires a specification and thorough analogical reasoning, as Albert Jonsen and Stephen Toulmin argue Jonsen, Albert R., Toulmin, S. (1988) The Abuse of Casuistry. A History of Moral Reasoning. University of California Press. P. 330. . Thus, it is better to consider the relation between cases and general judgments (i.e., principles) dialectically as only partially deriving from each other and mutually modifying.

The rule-based approach argues for stronger theories and guidance. Here are some examples of rules: do not kill; do not cause pain; do not disable; do not deprive of freedom or pleasure; do not deceive; keep your promise; do not cheat; obey the law, and do your duty Gert, B. et al. (1997) Morality and the New Genetics. Sudbury, Mass.: Jones and Bartlett. . James Childress criticizes this school of thought, because following these rules may lead to a highly uncertain outcome. For example, if after a terrible accident, a person refuses a blood transfusion on religious grounds (e.g., being a Jehovah's Witness), the physicians still can carry it out once they lose consciousness, which transgresses a patient's freedom of choice and freedom in general.

1.2 The Application of Principles in Bioethics

How exactly shall we apply ethical principles, whatever they might be, to medical practice? As James Childress suggests, before that application, we have to define the so-called application network. It works only in the case if �(a) the principle's scope and range of applicability can be firmly established, (b) the principle's weight or strength can be established a priori, and (c) the principle will never come into conflict with other equally significant principles.� Childress, James F. (2009) �Methods in Bioethics,� p. 25. There are situations when principles contradict each other, the most common example of which is the conflict between benefiting patients and respecting their free choices. In such cases, the ethical link is realized in two ways: we either select one that suits the situation better or define the hierarchy and apply both accordingly.

Reflective Equilibrium Method

These ways of resolving contradictions are traditional, but there is a more modern one, which also answers the multilateral critics on principlism - a method of reflective equilibrium (RE) Ibid., p. 46. . John Arras distinguishes between two types of RE. The �narrow� one is when we choose decision-making methods intuitively and then legitimize them by some specific principles. On the contrary, the �wide� one says that we should take into account all the laws that can be applied in the case, all kinds of criticism, opposite points of view, theories, contradictory judgments, etc., and only then make a decision. If in classical principlism, we try to consider which of the principles are most consistent with the sources of moral values like the Bible, Kant's moral imperative, or Confucius' teachings. In RE, we ought to study all positions and decide which of them agree with each other the most.

Today, we can consider RE in its �wide� version being the dominant principlist methodology - at least, according to such highly influential scholars in the field of bioethics as Beauchamp and Childress. That is noteworthy because, in their criticism of principlist approaches, many Chinese authors ignore RE, which forms a �big, all-encompassing methodological synthesis.� Ibid., p. 68. Of course, this method features many flaws, including high labor-intensiveness and time-consuming; it resembles somewhat an intellectual puzzle for a desk scientist writing an article rather than a guide to action for practitioners. The authors working on the RE theory often ask is a global synthesis able to bring about an ideal hierarchy of principles or systematize their interrelation. Unless we consider some of these positions divine, universal, and �written in the in the book of nature,� it is most likely impossible.

Paradigm Cases Method

Another compromise solution is to exploit �paradigm cases,� Veatch, Robert M., Guidry-Grimes, Laura K. (2019) The Basics of Bioethics, 4th ed. Routledge. P. 4. i.e., past controversial precedents that have been successfully resolved and resulted in absolute public consensus. Along with secular law, they can be drawn from other authoritative sources: thus, the authors of The Basics of Bioethics cite biblical stories as examples. That indicates their relativistic approach: the main thing is that a story �works� through bringing people together and uniting them on a particular issue. Such an approach that similar cases generally should be resolved the same way is characteristic to the US (where the authors come from) with their common law system. Reliance on such paradigm cases is also called casuistry.

Virtues, Values, and Duties

Another starting points for bioethics also include virtue and duty ethics. The former is a moral theory of good intentions, will, and personal qualities. Along with beneficence, the theorists of bioethics often discuss benevolence, which takes into account one's intensions rather than particular actions.

A doctor's personality is associated with the concept of duty, which is vital for both bio- and medical ethics. As Laura Guidry-Grimes and Robert Veatch indicate, a physician has some prima facie duties, which can sometimes contradict each other. They draw an example: after a tough day, the doctor promised a fatally ill patient to assist his death one day, when the pain becomes unbearable. Letting alone the question of whether he had the right to make such a promise, we consider here two prima facie duties, i.e., keeping promises and not causing death. In this case, he is not able to fulfill both at once because they are mutually excluding. The authors say that in these circumstances, it is necessary to choose what they call duty proper, hierarchically superior to other conflicting principles Ibid., pp. 69-70. .

To form such a hierarchy, we need to understand what is right and what is not, and to determine the value basis of a particular culture to know how its ethical system is built up. That is the value theory's domain. While we define values in a given social context, it is necessary to identify intrinsic values, which have compelling character and include the utmost importance of human life, liberty, family, social order, etc. Thus, in the West, they would prefer the former two, in China - the latter two values. Some scholars set these intrinsic values against extrinsic ones like, for example, money, which has an indirect significance and can be used in support of other values.

1.3 Main Subjects of Bioethics

Now, let us consider the key issues and concepts of bioethics.

Autonomy

The word �autonomy� comes from the Greek autos (�self�) and nomos (which means �law,� rule,� or even �governance�). In other words, to be autonomous is to live according to laws, principles, and values established by oneself. In his article in The Oxford Handbook of Bioethics, Bruce Jennings cites modern philosophers calling autonomy �the final level of moral development,� to which a child ideally should ascend at the final stage of his or her moral and rational development. Thus, according to a definition of Canadian philosopher Lawrence Haworth, autonomy is obtaining and possessing �critical competence.� Jennings, B. (2009) �Autonomy,� pp. 77-78. In The Oxford Handbook of Bioethics.

The concept of autonomy is, to a large extent, based on the works of Immanuel Kant, John Stuart Mill, and Isaiah Berlin. It implies the supremacy of freedom and independent choice for all people with no exceptions. According to Jennings, its application in American medical practice means that doctors should provide their patients with objective information and avoid any personal judgments that could affect the patient's further actions. For example, it affected the introduction of in vitro fertilization (hereinafter referred to as IVF) practices in the USA in the 1980s: patients were not told much about the medical and social threats of this new method of curing infertility, as the doctors believed that this would be a paternalistic gesture and affect their decision on the procedure, which is not acceptable. Of course, we do not ignore their commercial benefit of practicing IVF, too.

Besides, the principle of autonomy forms the most fundamental rule of both medical ethics and bioethics. For the first time, it was formulated in 1946 in the Nuremberg Code as the �notion that the patient or subject has the right to be informed of the relevant facts of what is being proposed and to approve or disapprove before the physician proceeds.� Veatch, Robert M., Guidry-Grimes, Laura K. (2019) The Basics of Bioethics, p. 25.

Now, this formula is generally accepted in Western medical practice, applied to all the particular cases. For example, considering organ transplantation from a living donor, the medical personnel should take into account the following factors, which demonstrate the patient's real autonomy of choice:

- Whether the donor is entirely sane and self-aware, is not under the influence of drugs, depression, trauma, or mental confusion;

- Whether the donor was given comprehensive and accessible information about the procedure and its inevitable or optional consequences;

- Whether there was not any coercion, misinformation, social pressure, or other factors that could undermine their free choice.

There are two elements of autonomy, which are, at the same time, two traditions of conceptualizing this notion. The first, called objective autonomy, was initially formulated by Locke and Rousseau but embodied fully in the works of Kant. The famous German thinker spoke less about freedom than about one's moral duties, which are to be determined according to rational consideration. On the contrary, subjective autonomy, the principles of which were developed by Mill and Berlin, favors personal freedom over moral duty prone to be imposed �from above� by external authority of the state, the religious or another community.

Autonomy is crucial for our research not only as one of the essential concepts in Western bioethics but also as one which faces most enmity and misunderstanding from the part of non-Western theorists, including Chinese ones. Emphasizing the differences between the so-called �Eastern� and �Western� mentalities, they regularly contrast individualism and autonomy with Chinese social responsibility. In the second chapter, I will talk more about Chinese criticism of Western bioethics.

It is noteworthy that criticism of autonomy comes not only from the Chinese. At least since the 1970s, it has been attacked by Christian and Islamic theologians, philosophers of all kinds, and feminists, to name a few. Their accusations mostly refer to �narcissism,� �hedonism,� �egoism,� �expressive individualism,� and the ability to �undermine the moral order.� Jennings responds to this criticism with the argument that although social well-being, interconnections, and the legal order are great things, human life will still be unworthy and inferior without individual freedom and autonomy. �Autonomy allows one person to demand respect from another as a matter of right. Not to ask meekly for respect as a matter of goodwill, friendship, or charity, but to demand it. Proudly,� he concludes (italics in the original) Ibid., p. 81. .

Death

As an essential phenomenon for all human cultures and religions, death is one of the main issues of bioethics, too. However, it was put in the list only recently: just a few decades ago, as Guidry-Grimes and Veatch note, we knew perfectly well when a person is alive, and when they are dead. The development of medical technologies such as cardiopulmonary bypass (CPB) or ventilator, which can take over the function of lungs and heart, has made the definition of death unclear. Once �death,� whatever we mean by this term, occurs, the moral status of a person changes, and one ceases to be an object of most moral obligations of physicians, relatives, or anybody else. The medical personnel is no longer required to maintain life support systems, and organs of the deceased could be taken away and transplanted to others to save their lives.

When exactly does the death occur? There are three main approaches to the problem. The historically first and most traditional one is the somatic-oriented approach, which treats death as the irreversible loss of bodily functions, primarily cardiac and respiratory ones. This position often stems from the specific vision of the Abrahamic religions (Judaism, Christianity, and Islam), according to which human life ends when the �breath of life,� which God breathed into a person, leaves them. In many countries, including China, this definition of death is still dominant. In the US, for example, some ethnic minorities and religious people can legally demand physicians to apply it to them or their relatives.

Another two approaches focus on the brain and its functions. The most widely spread one is the so-called whole-brain-oriented approach, which interprets the death as the irreversible loss of all functions of the entire brain. Another view is labeled as higher-brain oriented. According to it, death is the loss of higher-brain functions responsible for perception, consciousness, and the organism's integrity.

Today it is not in legal practice almost anywhere in the world, but there is a vivid discussion about its potential benefits. According to the authors of The Basics of Bioethics, such an approach makes sense since a person, whose consciousness and all sensory functions are irreversibly lost, still may retain some reflexes, which would indicate that their brain is not dead entirely. If a higher-brain death definition is legalized, many people will no longer be maintained in a vegetative state due to the loss of these higher-brain functions Ibid., p. 45..

One of the most challenging death-related bioethics issues is euthanasia, its theoretical possibility or impossibility, what should be its reasons, legal, and medical standards. There are two types of euthanasia: passive - when the patient dies because of the cancellation of maintenance therapy, and active - when the patient is voluntarily given the medications accelerate the onset of their death. At the time being, more countries legalize euthanasia, and many public organizations advocate its legal embracing. Since in China, the majority of the population fully supports the need for its legislative legalization (support rate is higher within younger and more educated groups; among the Shanghai students it is about 80% with 3% disagree) 2007 data. Today the support rate level must be much higher. Shi Weixing. (2010) Biomedical Ethics (Shengwu yixue lunli xue). Zhejiang Education Publishing House. P. 241., we can suggest that the government is going to take appropriate measures soon.

Beginning of Life

In bioethics, the moment of death is not purely theoretical construction. It is also the moment when a person loses their moral status as a living being with its rights, dignity, autonomy, etc. But when exactly does a person receive it? When a human is conceived, reached a certain age - for example, 40 days, - or born? This question is intimately connected with such highly disputable bioethical issues as abortion and the use of stem cells.

One of the possible approaches, proposed by Guidry-Grimes and Veatch, is to acquiring moral status is to reverse the point when a person dies and loses it. Thus, the somatic-oriented approach starts with a dilemma because the contraction of the heart muscle begins in the early stages of embryo development, but blood circulation starts quite late. It occurs in 24 weeks, just about the same time when the higher brain functions are formed. And that is when, following the higher-brain-oriented approach, an embryo becomes a legitimate person. The whole-brain-oriented method can be applied to a fetus that has developed capacity for neurological bodily integration and is now able to interact with the environment, which occurs at the age of 8-12 weeks.

The usage of stem cells poses several issues at once. To begin with, these are undifferentiated cells, and both embryos and adults have them. Their unique ability is that later, they can transform into different types of cells of organs and tissues. The first question that arises concerning the usage of any kind of stem cell is whether we have the right to intrude into the human body's natural structure. Some people suggest that we do, some - that we do not. The second question touches upon the stem cells of the embryo because we cannot take them without destroying it. Conservatives and the Catholic and Orthodox Christians, in particular, believe that a person with the entire set of moral rights appears immediately after conception when its genetic code is determined. From this position, destroying an embryo is equivalent to the killing of a human being.