Bioethics with Chinese characteristics: cultural contexts and modern trends

2.1 Brief History of Bioethics in China

As I did in the first chapter with bioethics in general, I regard books and magazines, conferences, and government regulations as milestones in the history of the Chinese version of the discipline. As we will see, in terms of raising bioethical questions at academic level, China was not far behind the United States. The first large-scale bioethics initiative in the country was the Conference on Philosophy of Medicine held in Guangzhou in 1979, which focused on life-sustaining technologies, new reproductive technologies, organ transplantation, etc Ibid., p. 58.. In 1980 the journal Medicine and Philosophy (Yixue yu zhexue, ��w�^�N�w) was launched featuring articles on brain death and euthanasia, and in the next decade bioethical courses for medical students became obligatory Henning, W. �Bioethics in China: Although National Guidelines Are in Place, their Implementation Remains Difficult,� Reports, 7(9). URL: [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1559670/].. Despite of early formulation of these problems, in practice the situation has not changed significantly: both scientists and most of the public continue to talk about the need to introduce brain death criteria and legalize euthanasia in China, but until now that never happened.

In 1986, a workshop on bioethics was held for young teaching staff in medical schools in Nanjing City organized by Southeast University and the Railway School of Medicine. Many of the participants later became the backbone of bioethics in China. In 1987, the first book of Qiu Renzong dubbed Bioethics was published and immediately became very popular: about 50,000 copies were sold in a short period Zhai, X. (2003) ABA Country Report for China 2003. URL: [https://www.eubios.info/EJ141/ej141d.htm].

In 1988, two important conferences were held: the first National Conference on Social, Ethical and Legal Issues in Euthanasia in Shanghai and the National Conference on Social, Ethical and Legal Issues in Human Artificial Reproduction in Yueyang, Hunan Province Qiu, R. (2006) �Cloning Issues in China,� p. 58. In Roetz, H. (ed.) Cross-Cultural Issues in Bioethics.. Since then, national and local conferences on bioethics are organized in China almost every year, covering every important topic and problem.

Breakthroughs in Chinese bioethics have often happened after some high-profile world events took place. One of them was the release of news about Dolly the sheep, the first cloned mammal in history, in 1997. According to Qiu Renzong, it was after this when �bioethics began to be institutionalized on the Mainland and it became a focus not only of academics but also of the government and the legislature, the public and the mass media� Ibid., p. 60.. Not directly related to bioethics, but quite comparable event occurred in May 2017, when Google's software AlphaGo defeated best Chinese Go player Ke Jie. The resonance from his loss was so high, that the State Council published a plan for the development and implementation of artificial intelligence in order to become a world leader in this area by 2030 Lee, K.-F. (2018) AI Superpowers: China, Silicon Valley, and the New World Order. Houghton Mifflin Harcourt. P. 17..

Since the 1980s, China has been constantly catching up with Europe and the United States in the field of biomedical technology. For example, in 1986, Qingdao University School of Medicine established China's first human sperm bank, and in 1988, China's first test-tube baby was born in the Hospital of Peking University Medical College (the first baby in history conceived by IVF was born in 1978 in Manchester, UK). By the end of 2007, there were more than 90 medical institutions carrying out assisted reproductive technologies in China, indicating the country had reached a high level in this scientific area Shi Weixing (2010) Biomedical Ethics (Shengwu yixue lunli xue). P. 177..

In October 2007, Chinese scientists successfully completed the first Chinese genome map, which is also the first complete genome sequence map of Asian person. It can be seen as a kind of answer to the Human Genome Project - international initiative leaded by the USA, which goal was to determine the DNA sequence of the entire human genome. The research's draft was published in 2000, and in 2003 scientists released the decryption of the essentially complete genome. The latest milestone took place in 2006 with the publishing of the last chromosome Noble, I. (2003) �Human genome finally complete,� BBC News. URL: [http://news.bbc.co.uk/2/hi/science/nature/2940601.stm].. Accordingly, the Chinese were just a bit late.

2.2 Chinese Bioethics Dictionary: Some Illustrative Examples

A valuable source in the study of Chinese bioethics is Chinese language itself. In this section of the thesis I will make a brief dictionary of some terms that contain meanings and �arguments�, both intrinsic and contextual, that give answers to some important bioethical questions, especially if we make a cross-cultural research. Our linguistic analysis revealed several ways of how the terms can contribute to the study of Chinese bioethics. First one is the context of using particular words.

The author of the thesis discovered, that the term `eugenics' (ɬ���w, youshengxue) does not have (or almost does not have) negative connotations in Chinese language. There is a special expression `Nazi eugenics' (?��ɬ���w, nacui youshengxue) to describe corresponding activities in Germany under Hitler's rule, but in general for Chinese people eugenics is just a science that can and should have a positive impact on the society. What is also specific, when the author of a biomedical ethics textbook talks about killing physically and mentally disabled people in the Nazi Germany, he uses the term `euthanasia' (��?��, anlesi). If we go to the webpage dedicated to youshengxue in the Chinese analog of Wikipedia, Baidu Baike (�S�x�S��), the first phrase we see will be the following: �Eugenics is the most important issue in marriage and family� (�ɬ�ͬO�B�éM�a�x�̭��n��??�h) �Eugenics,� Baidu Baike Online Encyclopedia. URL: [https://baike.baidu.com/item/ɬ���w/1172980?fr=Aladdin]..

Shi Weixing begins the chapter ��ugenics and Fertilization Control� of his book with a statement: �controlling the number of people and improving the quality of the population is a basic national policy of our country� Modern eugenics is a multi-disciplinary and comprehensive discipline that uses the principles of genetics to improve human genetic qualities through social measures and medical methods. Its purpose is to apply the laws of genetics to human reproduction, thereby ensuring and improving the quality of the entire human population� Shi Weixing (2010) Biomedical Ethics (Shengwu yixue lunli xue). P. 207..

Author of �Biomedical Ethics� speaks a lot about the ethical justification of eugenics. He interprets the ban on marriages between closely related people in China, Roman Empire and among the Jews as ancient practices of eugenics and refers to Plato, who wrote about the state's obligation to cultivate and select the best of its people. Then, he proceeds to European and American committees dealing with eugenics research and practice in the early XX century. Eugenics of that time, he notes, was primarily concerned with the prohibition of reproduction for people with serious genetic diseases, forced sterilization and abortion. Then he describe the transition from preventive eugenics (yufangxing youshengxue, ?�h��ɬ��) to evolutionary one (yanjinxing youshengxue, ��?��ɬ���w) in the latter half of the XX century, after the World War II Ibid., p. 209. . However, he discusses the Holocaust, Japanese nationalism and racism in the US towards the black population in another section of the chapter, identifiyng these episodes as �catastrophic� for the eugenics that made this science �suffer enormously�.

It is also worth discussing how the term �sterilization� (jueyu, ?�|) is used in this book. The situation is similar with the previous one: in Western languages �sterilization�, if refering to humans, has decidedly negative connotations. Shi Weixing's approach is different. He distinguishes three types of sterilization and consider acceptable all of them. These are therapeutic sterilization (which is carried our if pregnancy is dangerous for the woman's health); eugenic sterilization (youshengxing jueyu, ɬ����?��) to be applied to people with serious genetic diseases; and contraceptive eugenics that can also be used as a tool of government birth control. Shi Weixing also differs voluntary and involuntary types of sterilization Ibid. P. 217..

Next issue I want do discuss is a special perception of physicians in Chinese culture. It can be well illustrated by the expression �angels in white� (baiyi tianshi, ���ߓV�g), which is a synonym for doctors and medical personnel. These four characters reflects especially respectful attitude towards them that determines the paternalistic structure of doctor-patient relationships. There is another saying: �Physicians have the heart of parents� (yizhe fumuxin, ��ҕ���S). Edwin Hui also notes that this special status can �legalize� paternalistic attitude of doctors Hui, E. (2004) �Personhood and Bioethics: A Chinese Perspective,� p. 40. In Qiu, R. (ed.) Bioethics: Asian Perspectives. . Within this personal kind of doctor-patient relationships, it is not ethically troubling for them to, for example, withhold some information or not comply with the principle of the informed consent in case they think it will be more beneficial for patient.

Based on the specificity of these two expressions, we can assume that within the framework of Confucianism, the figure of doctor may well be included in the basic social hierarchies (such as father - son, emperor - subordinate), occupying a quite high position. Peimin Nie reinforces this idea by quoting Sun Simiao, 6th century Confucian doctor. He said: �A superior doctor takes care of the state, a mediocre doctor takes care of the person, an inferior doctor takes care of the disease� Ni, P. (2002) �Confucian Virtues and Personal Health,� p. 31. In Fan, R. (ed.) Confucian Bioethics. . Thus, in Chinese culture doctors are someone much higher than those who just diagnose illnesses and prescribe medical treatment. This does not correspond to the western tendency of reducing doctors' paternalism, which can be traced by the evolution of medical vows from the Hippocratic oath to the present day.

Next, we move on to the basic words of the Chinese language, which relate to the domains of life, body, and health. Their structure, origin and contexts of use can tell a lot about how Chinese bioethics can be constructed.

Qi, �� is a kind of �psychic energy� and one of the key categories in Chinese thought, both in Confucianism and Taoism. It was elaborated by such crucial figures as Mencius (372 - 289 B.C.) and Zhu Xi (1130 - 1200).

I have discovered, that in modern Chinese medicine there is a curious kind of interpreting the concept of qi. Sun Xiu Fen, Doctor of the State Hospital of Traditional Chinese Medicine in Dalian, explained that qi is an electric current, which is proved to be produced by human cells. �Scientists notice that human cells produce an electric current. When a person dies, this current stops. We call this current a qi energy, this is the force that makes the cells move. More electricity we have, faster is the cell movement, and longer lives a person. Less electricity, the cells move slower, a person get sick or get tired easily. Children have more current; that is why they almost never feel tired. Current is life, the movement of life� Kudryavtseva, �. �The Movement of Life, an Interview with Sun Xiufen (?�G�),� from the personal archive of the author..

Qi is widely associated with life in Chinese culture. It has a lot of meanings including �breathing�, �gas�, �air�. Consequently, meiqi (�v��), or not having qi, means to not breathe, or to die. I have not seen such references in literature, but having this meaning, the concept of meiqi can be an argument if favor of somatic criteria in determining death, that is based on the cessation of respiratory and cardiac activity.

The concept of shen (�g) is very important in the process of rethinking Confucian ethics for the construction of bioethics. Shen means �I�, �self�, and at the same time it means �body�. In different contexts shen can refer to body in a literal sense or to something more - to �essence� of man, the physical existence opposed to xin (�S), the mind. Of course, it is not an opposition analogous to binary opposition of body and soul as it takes place in Christian philosophy. In Chinese thought, mind and body complement each other, and the latter can not have negative connotations. It seems that without such a polysemy and �continuity� of such terms as shen Confucious bioethics would not be possible.

The division between two �types� of life, shengming (����) and shenghuo (����), is characteristic for Chinese thought and have direct implications on bioethical decisions. The first one means �life� in a biological sense, and the second one refer to life of the person, who is firstly a social entity. Thus, shengming, or non-social life, can not have the same value as social one - and this, in it's turn, can be regarded as a counterargument against life-sustaining treatment of patients in permanent vegetative state.

The term rensheng (�l��) means �human's life�. It contains the character sheng (��) that means �to come out� or �to be born�. It supports the idea that a person appears at the moment of his/her birth, not before, and can have some implications on treating fetuses and embryo experimentation, which are important subjects of bioethics.

Chinese opponents of surrogacy can refer to the term qinsheng?�� that can be translated as �birth�, or �biological�. The term qinsheng fumu?�ͤ���, �biological parents�, points to the fact that only those who give birth can be called a real mother Cheng-Tek Tai, M. (2009) �Natural or Unnatural - An Application of the Taoist Thought to Bioethics,� Tzu Chi Medical Journal, 21(3): 273..

Another domain of our linguistic analysis is occupied by Confucian terms and concepts. They are actively used by Chinese scholars to construct local bioethical system based on authentic Chinese culture, as well as to criticize Western bioethics. First of all, they apply to basic virtues reflected in Five constants (wuchang, �܏�) and Four virtues (sizi, �l��). Some of them are used much more often than others, so we will speak about them.

According to Po-Keung Ip, Confucian ethics is build on the moral ren-yi-li normative structure Ip, P. (2004) �Confucian Personhood and Bioethics,� p. 50. In Qiu, R. (ed.) Bioethics: Asian Perspectives., where ren (�m) is humaneness, yi (?) is justice and righteousness, and li (��) is rituals. For obvious reasons, the latter principle is mentioned less often than the rest. As Fan Ruiping said, �Rituals can be revised according to the central concern of the virtue� Fan, R. (2004) �Towards a Reconstructionist Confucian Bioethics,� p. 63. In Qiu, R. (ed.) Bioethics: Asian Perspectives. .

Ren and yi are the concepts of huge importance: Chinese bioethicists are offering to resolve the most existential promblems according to them. In his article �Confucian views on suicide� Lo Ping-Cheung writes: �the preservation of our biological life is a good, but not the supreme good; death is an evil, but not the supreme evil. Since the cardinal moral values of ren and yi are the supreme good, it is morally wrong for one to preserve one's own life at the expense of ignoring ren and yi Lo, P. (2002) �Confucian Views on Suicide,� p. 71. In Fan, R. (ed.) Confucian Bioethics. .

However, ren is the most important concept of two. Edwin Hui notes, that in the Analects this word appears 105 times, more than any other important term. Following Confucius, Chinese bioethicists speak a lot about ren, emphasizing its great value. For them, it is a central concept, from which all other Confucius terms related to humanity and compassion were developed: �a relational term� used to describe the relational/social nature of man� Hui, E. (2002) �A Confucian Ethic of Medical Futility,� p. 149. In Fan, R. (ed.) Confucian Bioethics., �both a capacity of humanity and the act�, the term that represents �a myriad of morally desirable conduct, or behavior exemplars� Ip, P. (2004) �Confucian Personhood and Bioethics,� p. 51. In Qiu, R. (ed.) Bioethics: Asian Perspectives., etc.

Xiao (�F), or filial piety, is not only a central virtue in Confucianism, but also a very influential concept in Chinese bioethics that has many different implications. Xiao is put in the very center of Chinese social structure by a number of scholars; they also regard it as a basic impetus of love. Fan Ruiping put �love� in the basis of ethics and compare the way it manifest itself in different cultures: �The foundation of Christian love is a creative tie between God and man; the foundation of Buddhist love is a causal connection among all beings; and the foundation of Ancient Greek love is a romantic union between man and woman (or man and man). Unlike any of these, the foundation of Confucian love is a blood-tie between parent and child� Fan, R. (2004) �Towards a Reconstructionist Confucian Bioethics,� p. 61. In Qiu, R. (ed.) Bioethics: Asian Perspectives. .

The authors I have read say that xiao creates a structure for the relationships based on mutual care and, the most important for us, it makes a family, not an individual, a real subject in bioethical issues. There are also some specificities in application of xiao from the point of view of bioethics: performing xiao is so important for the Chinese, that many people reject withdrawing life-extending measures for their parents even if they stay in a vegetative state and there is no chance they can recover Hui, E. (2004) �Personhood and Bioethics: A Chinese Perspective,� p. 41. In Qiu, R. (ed.) Bioethics: Asian Perspectives.. They think that this kind of passive euthanasia will be against the principle of filial piety, and they should take care of father and mother until the �natural� end.

The virtue of shu (��) is also definitely worth mentioning, especially since it is very understandable from the contexts of Western culture. Confucius explained it in following sentence: �Do not do to others what you do not want them to do to you� (Analects, 15:28).

It is also worth noting that the emphasis on virtues is a characteristic feature of Chinese bioethics, where personal virtues and goodwill of decision-makers are placed above established rules, human rights, and patient's autonomous choice. Confucian culture is not egalitarian, people are not equal and do not have equal rights. Po-Keung Ip quotes Mencius who identifies five types of human relationships: emperor-officials, father-son, brother-brother, husband-wife and between friends (Mencius 3A:3) Ip, P. (2004) �Confucian Personhood and Bioethics,� p. 51. In Qiu, R. (ed.) Bioethics: Asian Perspectives.. Relations in these pairs are subordinated and in some sense unequal. There is a special expression zunxian (��?) translated as �to honor the decent, talented people� that depicts this principle as a special virtue. If taken seriously in medical practice, this term would definitely become a pro-paternalistic argument against equal rights in the decision-making process.

Finally, we should discuss an �instrumental� term quan (?), an important concept in Confucianism, which can be understood as an imperative to weight the circumstances before making the decision. It is opposed to the term jing (?) that can mean standard, normal, and not demanding any concerns Shen, V. (2013) (ed.) Dao Companion to Classical Confucian Philosophy. Springer Science & Business Media. P. 324. . Quan is used by Chinese bioethicists in the sense quite close to the idea of �double effect� that we discussed above in the context of secular western bioethics and Catholic bioethics. In practice, it means that in situation of two confronting principles we can choose one and temporarily ignore another. Chen Xunwu propose an illustrative example from the Mencius: �Though the principle of propriety requires that a man and woman (who are not a married couple) should not touch each other physically, a man would be a wolf if he does not give his hand to his sister-in-law and rescue her when she is drowning in water (Mencius, 7B:17)� Chen, X. (2002) �Experimenting with Human Subjects,� p. 228. In Fan, R. (ed.) Confucian Bioethics. . Here, we see a principle of propriety and principle of ren (humaneness, compassion, benevolence) that can not be applied at the same time, but the second one, which can save a human life, evidently overweight the former.

2.3 Construction of Chinese Bioethics

There is no surprise that Confucianism serves as the fundament for the formation of Chinese bioethics. In recent decades, China began reviving it as a philosophy, ideology, and religion. On the contrary, Taoism plays a kind of secondary and somewhat supportive role, rescuing the situation in the issues Confucianism has historically ignored - the most prominent example is death. Our observation showed that in Chinese bioethics as a research field, there are several times fewer publications and references to Taoist bioethics that to Confucian one, and Buddhism is almost impossible to find. However, the authors widely use the cosmological concepts that are common for both Confucian and Taoist thought, like the vital energy qi, the interaction of yin and yang, or the five elements that have to harmonize with each other.

The primary and rather severe problem in constructing Chinese bioethics is that Confucius almost never touched upon such topics as death or health. The teacher speaks primarily about morality and human relationships. The much-quoted proof for this is a saying in the Analects (11:12): �We do not know life, how can we know death?� How do they solve this problem? Jing-Bao Nie offers a hermeneutic approach to the study of Confucian texts. However, I suggest that his methods are closer to religious allegorical exegesis than hermeneutics. What he does is transferring moral notions to the level of physicality, illness, and recovery.

Sometimes an opposite approach is used: for example, such a curious topic in traditional Chinese medicine as human drugs - the medications made from parts of the human body - is proposed to be studied not literally, but allegorically, in order to find what the practices of using such drugs can tell us about virtues and the relationships between people.

In keeping with this approach, traditional medicine can never be regarded as outdated, so we can and should reckon with it today. �Chinese medicine is fundamentally compatible with modern sciences, and moreover, value that Chinese medicine is able to provide provides a sort of spiritual guide revelation or enlightenment for biomedicine owing to its rich philosophical wisdom and strong holism,� - writes Nie Jing-Bao Nie, J.-B. (2002) � `Human Drugs' in Chinese Medicine,� p. 174. In Fan, R. (ed.) Confucian Bioethics. . In the article �`Human Drugs' in Chinese Medicine and the Confucian View: An Interpretive Study� he observes a pharmacological text Bencao Gangmu (1597) written by Li Shi-Zhen, who was a physician, naturalist, and pharmacologist considered a father of Chinese medicine. Bencao Ganmu contains description and instruction manual for different kinds of drugs, including those made of parts of the human body. There are thirty-five of them: hair, fingernails, earwax, tears, bones, etc. Ibid. All of them have useful properties, but not all are ethical to use, says Li. So are, for example, flesh, bones, and internal organs.

Nie believes that we should not judge human drugs from the perspective of modern Western medicine. As a subject for more detailed analysis, he intentionally chooses such a human drug as pubes, which is somewhat �provocative� for a contemporary reader. Again, the author proposes an approach, which he calls hermeneutical or interpretative, but which resembles the most metaphorical one. He suggests rethinking this medical practice in ethical and social categories: �Actually, the very short entry `pubes' in the Bencao Gangmu raises many interesting questions regarding Chinese views of the human body, gender difference, sexuality, the cause of disease, the magic character of number, the relationship between humankind and nature, the relationship between human beings and animals, etc.,� - he writes Ibid., p. 175. .

Another argument in adaptation of Confucian thought to bioethics is the profound continuity of the Chinese world, where space, nature, the human body, and morality exist inseparable, so the processes that take place within each of the fields are interconnected and reflect each other. If we consider person a psycosomatic unity, where physical and phychical elements are closely related to each other, then we can transpose the considerations on feelings, character and behaviour to the body and health, and vise versa. Here the notion of qi as of universal and omnipresent energy of life find itself very helpful: �for Confucians, to cultivate one's person is to nourish one's qi. To nourish one's qi is to exercise the moral virtues. And to exercise the moral virtues is to pursue personal health� Fan, R. (2002) (ed.) Confucian Bioethics. P. 9., - writes Fan Ruiping. He claims that it is a delusion to think that Confucianism does not say anything about the health. Peimin Ni makes such a bold statement, that I will let myself to quote a large passage: �I shall show in this paper that to Confucians, the moral virtues they advocate are means to obtain personal health. If we take the concept of health in the positive sense, namely, not merely as an absence of disease but as a state of more complete well-being, we can understand the whole of Confucianism as, though not reduced to, a system of health care (italics added by me). Furthermore, Confucian moral virtues can be understood as qualities that define a healthy person Ni, P. (2002) �Confucian Virtues and Personal Health,� in Fan, R. (ed.) Confucian Bioethics. P. 27..

The author's thought goes far beyond the idea that �good� Confucian society creates and environment that disposes to healthy life. According to his ideas, it directly affects human body: �[principles of Confucianism] are health care itself, like eating nutritious food, or doing physical exercises� Ibid., p. 40. .

However, we should not forget that Confucian tools of obtaining health (or any kind of well-being) stay the same - these are moral virtues and appropriate behavior. As we know, these qualities can be achieved only socially - from one's family to administration of the state.

That is why from the Confucian perspective, a Daoist hermit can not be called healthy, no matter how physically well he is and how long does he live Fan, R. (2002) (ed.) Confucian Bioethics. P. 12.. If someone stays out of the relations with people, his/her body condition does not make any sense.

Zhang E. address to helpful linguistic issues. She notes that the term xiu shen (�C�g, �self-cultivation�) can be attributed to the body because of the abovementioned shen character within, and at the same time it is interchangeable with yang xing (?��, �rectification of mind�). In addition, she cites a number of Chinese expressions that contain ti character (��), which means �body�, �organism�, and �physical� above all. These words, however, are habitually attributed to areas of cognitive activities and perception: ti hui (�̉�, to experience), ti cha (�̎@, to observe), ti yan (����, to verify), and ti ren (����, to comprehend). Zhang E. also mentions that �these processes in cultivating the self is considered a part of the embodiment of the Dao� Zhang, E. (2002) �The Neo-Confucian Concept of Body,� p. 57. In Fan, R. (ed.) Confucian Bioethics. .

If we consider the methods of Chinese scholars eligible and reasonable, their use of Confucian principles in the construction of bioethics can be evaluated as quite successful. Thus, the idea of personal health and perception of the body integrates in presenting the specific concept of personality. In the next section of this chapter I will analyze this concept in its opposition to Western one, and then proceed to the Confucian (and to a lesser extent Taoist) reasoning of birth, death, human enhancement and different biomedical technologies, that is of basic bioethical subjects of concern.

2.4 Criticism of Individualism, Autonomy and Human Rights

As I have shown in the first chapter of the thesis, individualism, autonomy and the following fundamental setting on human rights are crucial for contemporary Western bioethics. However, it is the main subject of attack for Chinese bioethisists. In challenging it, they make an accent on the alienation of Western individual from the society - in our opinion, not a paramount feature of autonomy.

Chinese scientists find the fundamental basis for determining �Western� personality in the special idea of substance that has the �aptitude to exist in itself as a concrete individual thing and not as a part of any other being� Fan, R. (2004) �Towards a Reconstructionist Confucian Bioethics,� p. 59. In Qiu, R. (ed.) Bioethics: Asian Perspectives.. And otherwise, in Chinese cosmos everything is connected and there is no such a thing to exist independently from the others. Another opposed feature is an idea that personality is not really connected to the body. It seems that Edwin Hui challenges the idea of a person from the time of Decartes, ignoring the philosophical and anthropological ideas of the next several centuries: �It may also incline an individual to be rigidly enclosed in self-absorption and self-encapsulation, resulting in a narcissistic life totally alienated from others� Without taking into consideration one's emotional life and subconscious mental world, an individual's inner unity cannot be maintained� Hui, E. (2004) �Personhood and Bioethics: A Chinese Perspective,� p. 32. In Qiu, R. (ed.) Bioethics: Asian Perspectives.. Nevertheless, he needs this rough comparison to emphasize a deep and crucial distinction between Chinese and Western perceptions of the world.

The very foundation of the former is a principle of interaction and relationships. The interplay of yin and yang gives birth to myriads of things, five elements in human body (and on all other levels) should be in harmony, otherwise he/she got sick, and humans' higher purpose, according to Confucianism, is to build perfect relationships with each other.

Basic hierarchial structure of human relationships was first given by Mencius. He spoke about five types of social connections: �Love between father and son, duty between ruler and subject, distinction between husband and wife, precedence of the old over the young, and faith between friends� (Mencius 3A:3) Hui, E. (2002) �A Confucian Ethic of Medical Futility,� p. 151. In Fan, R. (ed.) Confucian Bioethics. . Each role in these relationships involves its own set of virtues. The thinker also said: �The [carpenter's] compass and square produce perfect circles and squares. By the sages, the human relations are perfectly exhibited� (Mencius 4A:2) Po-Wah, J. (2004) �Confucian and Western Notions of Human Need and Agency: Health Care and Biomedical Ethics in the XXI Century,� p. 21. in Qiu, R. (ed.) Bioethics: Asian Perspectives..

There is a wide variety of sayings of Confucian sages that can support this idea. Xunzi (310-235 BC) among them: �[m]en are not as strong as oxes, nor do they run as fast as horses, yet how is it that oxes and horses are being mastered by men? That is because men are capable of social organization and animals are not� (Xunzi 7:9) Hui, E. (2002) �A Confucian Ethic of Medical Futility,� p. 147. In Fan, R. (ed.) Confucian Bioethics..

What is interesting, sometimes in their criticism of individualism and human rights Chinese scholars address to approaches that I have classified as secular alternative approach in the first chapter of the thesis. Qiu Renzong indicates �serious� doubts about the adequacy of principle of human rights in resolving bioethical and health problems and, to support this idea, addresses to feminism: �Feminist philosophers express concern about how an overemphasis on rights could obscure other important moral concerns such as power inequities, justice for particular social groups, and real divergence of cultural, religious and moral perspectives Qiu, R. (2004) �Bioethics and Asian Culture - a Quest for Moral Diversity,� p. 2. In Qiu, R. (ed.) Bioethics: Asian Perspectives. . He also states that in some situations individuals might need more help than rights.

2.5 Comparison of Bioethical Problems: China and the West

Informed consent

Informed consent is one of the basic settings of Western bioethics, naturally originating from the principles of autonomy (a person cannot make a truly autonomous decision if he is not aware of what is happening to her/him), medical veracity and justice.

However, in Confucianism it is considered a virtue when a child relieves parents of all burdens, be they physical, financial of psychological. This may also include the painful news of an incurable disease. As I have already mentioned, physicians in China will not find it ethically inappropriate to withhold information from patients as well, if they find it unnecessary or not beneficial for them.

Moreover, in Chinese worldview, the illness of person is rather a problem of family and society than his individual deal. That is why the principle of informed consent can be ignored. As noted by Edwin Hui, �a Chinese physician will likely follow the inclinations of the family to satisfy all the other social protocols inspired by the principle of ren, particularly the requirements of filial piety as perceived by the patient's family� Hui, E. (2004) �Personhood and Bioethics: A Chinese Perspective,� p. 40. In Qiu, R. (ed.) Bioethics: Asian Perspectives..

Organ Transplantation

As we saw in the previous chapter, medical practice of organ transplantation may have many bioethical challenges. If donor is a living person, the subject of largest concern is how dangerous for his/her own health this operation will be, and, consequently, if she/he makes absolutely conscious and not enforced by any pressures decision. In China, this problem of personal decision is not discussed in such detail. However, the concern is raised in such difficult and painful cases as organ transplantation from prisoners sentenced to death. According to Shi Weixin, before 2007, more than a half of the transplanted organs in China came from death row prisoners Shi Weixing (2000) Biomedical Ethics (Shengwu yixue lunli xue). P. 183.. The situation has changed a lot since then, mostly due to the reforms of Huang Jiefu, deputy director of the Central Health Committee of China. Now people can register online and give their consent to donate organs after death. In 2017 The Washington Post reported that more than 230 000 people have done so Denyer, S. (2017) �China Used to Harvest Organs from Prisoners. Under Pressure, that Practice is Finally Ending,� The Washington Post. URL: [https://www.washingtonpost.com/world/asia_pacific/in-the-face-of-criticism-china-has-been-cleaning-up-its-organ-transplant-industry/2017/09/14/d689444e-e1a2-11e6-a419-eefe8eff0835_story.html?utm_term=.ad49de44760c]., that makes China one of the most developed countries in this area.

In Chinese bioethics, we see a number of another factors affecting the field of donor transplantation. Earlier in this chapter I observed some features of perception of body among Chinese that makes them refuse organs' exchange and even surgeries in general. Edwin Hui also comments on this issue: �As the Book of Filial Piety (Xiao Jing) clearly states, �Our bodies to every hair and bit of skin are received by us from our parents, and we must not presume to injure or wound them: this is the beginning of filial piety�� Hui, E. (2002) �A Confucian Ethic of Medical Futility,� p. 153. In Fan, R. (ed.) Confucian Bioethics..

Shi Weixing points to the fact that organ transplantation can have an impact on personality. This phenomenon is being investigated in other countries See, for example: [https://www.medicaldaily.com/can-organ-transplant-change-recipients-personality-cell-memory-theory-affirms-yes-247498]; [https://www.sciencedirect.com/science/article/abs/pii/S0306987719307145]., but there is no such a problem in the discourse of Western bioethics, both secular and religious. We can suggest that it finds itself among the problems of Chinese bioethics because this �personality change� can affect family and social life of a person which is a major topic of concern.

Another interesting discussion about organ transplantation stays in opposition to the ideas I described above. Jing Bao-Nie reminds us about such practice of filial piety as using one's flesh as a human drug to cure parents. It was quite common in some periods of China's history. Nie's ethical analysis of this practice has led him to conclusion: �Ethically speaking, there is no fundamental ethical difference between cutting one flesh to cure his mother and donating one of his kidneys to save his mother's life� Nie, J.-B. (1999) � `Human Drugs' in Chinese Medicine,� p. 199. In Fan, R. (ed.) Confucian Bioethics..

In Western literature on bioethics, including the most up-to-date (up to 2019 inclusive), I did not encounter the issue of brain transplantation. In searching for publications on this subject, one will most likely find rather skeptical and even outraged reviews on the research of the Italian neurosurgeon Sergio Canavero and Harbin Medical University professor Ren Xiaoping, who experimented with head transplantation.

But in serious bioethical pieces, this issue is not usually addressed. It is therefore all the more surprising to see the section devoted to it in the 2010 textbook, which is Shi Weixing's Biomedical Ethics. The author says that brain transplantation is the �last bastion� of transplantology, and at the same time does not have fundamental technical obstacles. However, such an operation is associated with serious ethical issues such as relationship with the original family, the responsibilities related to childbirth and childcare, the psychological adaptation, gender issues, property inheritance, life insurance, etc. Shi Weixing (2000) Biomedical Ethics (Shengwu yixue lunli xue). P. 190. It is hard to miss that all these questions, again, are addressed to family and social life. It is also worth to emphasise this double bound given by bioethicist: ethical problems will arise in connection with brain transplantation, but, in principle, this medical technology can be applicable and resolve health problems in the future.

Death Issues and Euthanasia

There are two major topics in bioethics concerning death - death criterion and euthanasia. I will discuss the first one only briefly: in today's China somatic criteria is used (and theoretically - this issue should be investigated in more detail - it can be connected to the abovementioned idea of qi). Many scientist say the brain death criteria should be legalized: at least, it will significantly improve the situation with harvesting organs for donor purposes. But so far this has not happened.

As for euthanasia, we can distinguish three major trends for it's conceptualization. First one is the abovementioned indifference to discussions of death in classical Confucianism, as well as in Neo-Confucianism. 11th century philosopher Zhang Zai said: �In life I shall serve unresistingly, and when death comes, I shall be at peace� Zhang, Y.E. (2002) �The Neo-Confucian Concept of Body and Its Ethical Sensibility,� p. 54. In Fan, R. Confucian Bioethics. . Here, Taoism goes to work.

Second is an influence of Confucian suicide culture. Although this practice is rather controversial and full of internal criticism, it introduces to us a special concept of �good death� that can be used as an argument in favor of active euthanasia. And the third one is also aboventioned xiao virtue, which, according to Chinese authors, often makes people insist on sustaining their parents' life with intensive therapy even if there is no hope for the recovery.

Let us observe all these topics one by one.

The authors of the article on Taoism in the manifesto book of Asian bioethics argue that the Taoist concepts of equality of life and death give a chance to overcome anxiety and suffering in anticipation of death. For the Chinese who bear a very heavy burden of life obligations to the family and the state, Taoist ideals of simplicity and non-action will be quite helpful to perceive death as liberation and well-deserved rest.

In Taoist worldview life is continual, and life and death are one dynamic circle of Dao, where qi permanently transforms its form. Ping Dong and Wang Xiao-Yan suppose, that if people would accept this philosophy, they will accept death easily: �Taoist scholars suggest common people should abandon the small wisdom of distinguishing right from wrong and merge themselves into one body with tao or nature� Taoist theory implies that after taking a detached attitude towards life and death, people can fulfil their allotted life span more lightly and make sorrow, anxiety and suffering disappear without a trace� Dong, P., Wang, X. (2004) �Taoist Perspective on Life, Death and End-of-Life Care,� p. 153. In Qiu, R. (ed.) Bioethics: Asian Perspectives. .

The book Zhuangzi supports this view perfectly. At least a part of it, as considered, was written by Zhuangzi, philosopher who lived around 4th century BC. One of it's passages tells us how the sage adopted a new attitude towards the death of his wife: �When she died, I couldn't help being affected. Soon, however, I examined the matter from the very beginning. At the very beginning, she was not living, having no form, nor even substance. But somehow or other, there was then her substance, then her form, then her life. Now by a further change, she has died. The whole process is like the sequence of the four seasons, while she is thus lying in the great mansion of the universe, for me to go about weeping and wailing would proclaim myself ignorant of the natural laws. Therefore, I stopped mourning.� Cheng-Tek, Tai M. (2009) �Natural or Unnatural - An Application of the Taoist Thought to Bioethics,� Tzu Chi Medical Journal, 21(3): 273.

Taoism opens up as a perfect natural philosophy: �The Taoist view on "non-action facing nature" requires that people should respect nature, conform to the natural order, let nature take its course, and reject the attitude of seeking life and avoiding death� Dong, P., Wang, X. (2004) �Taoist Perspective on Life, Death and End-of-Life Care,� p. 153. In Qiu, R. (ed.) Bioethics: Asian Perspectives.. From this point we can proceed to bioethical issues. The respect to natural order is opposed to artificial extension of life: �According to that view, passive euthanasia, or withholding and withdrawing treatment, is appropriate in end-of-life care� Ibid., p. 154..

But how can we evaluate whether this extension of life artificial or not? Apparently, those who construct Taoist bioethics are guided, again, by the concept of qi and apply it in its sense of breathing. That corresponds to somatic criteria in determination of death: �In the case of a PVS [permanent vegetative state - the author] patient, if the patient can breathe on his own, he is still considered alive; but if this person has to depend on a life-support system to remain alive, the life is no longer natural. The removal of the system is to let the Tao be the Tao. Taoism, however, would oppose active euthanasia as it is an artificial way of ending life. Palliative care would be the Taoists' option to let nature take its course� Cheng-Tek, Tai M. (2009) �Natural or Unnatural - An Application of the Taoist Thought to Bioethics,� Tzu Chi Medical Journal, 21(3): 273..

In conclusions, this set of ideas reminds Catholic view. Catholics say that it is absolutely inapropriate to accelerate one's death in active euthanasia, as it will be against Natural Law and God's will. The same can be said about sustaining the life of PVS patients. They also emphasize the importance of palliative care.

In the article �Confucian Views on Suicide and Their Implication on Euthanasia� Lo Ping-Cheung discuss a kind of suicide he calls �other-regarding�: since ancient times and till 1911 (pre-modern period) it was generally evaluated positively Lo, P. (2002) �Confucian Views on Suicide,� p. 69. In Fan, R. (ed.) Confucian Bioethics.. In our opinion, no matter that active euthanasia cannot be called �other-regarding� suicide, the precedent of respectful suicide can open the door for the practice. It brings to life a concept of death with dignity, while dying in pain or being intensively treated in the unconscious state can be considered disgraceful.

In the very beginning of the chapter on euthanasia in Shi Weixing's book, we see a quote from a Friedrich Engels' letter to Friedrich Sorge, where he writes about the death of Marx from an lung abscess. Thanks to the achievements of modern medicine, - he says, - this death was possible to be delayed, which would have allowed philosopher to live a few more miserable years in a state of disability. But Marx would never have accepted this, and Engels agrees with him: it would be regrettable for such an outstanding person, as such a life is �a thousand times more miserable than death� Shi Weixing. (2000) Biomedical Ethics (Shengwu yixue lunli xue). P. 233.. The author quotes this passage devoted to Karl Marx, this highly important figure for a socialist society, such as China, as a sufficiently weighty argument in favor of euthanasia.

Another side of the coin is that in the concepts of �good death� and �other-regarding suicide� in Confucianism negative reasoning of suicide cannot be accepted. For example, it is not a dignity to die sooner because the person became a burden for his/her family. Lo Ping-Cheung confidently claims that �according to the Confucian social vision, the good society is one in which, through an extensive support network, �widows, widowers, orphans, the childless, the disabled, and the sick are to be well taken care of�� [a passage from The Book of Rites] Lo, P. (2002) �Confucian Views on Suicide,� p. 93. In Fan, R. (ed.) Confucian Bioethics..

In the end of the section I would like to address to the public opinion on the topic. Euthanasia is not legalized in China now, although most bioethicists advocate this.

Public polls data shows that not only people in academia, but the majority of people agree with it. In 1995, 52 percent of poll participants expressed support for the legalization of both passive and active euthanasia, 14.43 percent supported active euthanasia, 8.2 percent opposed both, 16.8 percent were neutral Shi, D., Yu, L. (2004) �Euthanasia Should Be Legalized in China,� p. 166. In Qiu, R. (ed.) Bioethics: Asian Perspectives.. The latest public opinion research took place in 2013, with 3400 respondents from 34 cities. It showed that a percentage of sympathizers grew: about 70 percent said they do not oppose euthanasia Wang, H. (2013) �Most Chinese have Open Mind toward Euthanasia,� China Daily. URL: [https://www.chinadaily.com.cn/china/2013-12/31/content_17206128.htm]..

Reproductive technologies, abortion and human enhancement

In ethical revision of IVF-related technology, the subject of largest concern of Western bioethics (to a greater extent this is the case of religious approaches, but not only) is the selection of �best� embryos and discarding the others (in IVF operations, the number of created embryos greatly exceeds the number of those that will be implanted) and problems of human enhancement through genome editing. The latter refer to the autonomy of a future child and social misbalance and gap between those privileged people who can afford it and those who do not.

In turn, Chinese bioethics primarily focuses on family issues. Is the use of donor biological materials or the services of a surrogate mother destructive for a family? Can an unmarried woman use the services of artificial insemination? Most likely, she does not.

According to Shi Weixing's �Biomedical Ethics�, a human embryo can not be considered a person, so there are no taboos or serious debates around experimenting, selecting and discarding them. Since embryos are not social, but biological individuals, dealing with them do not harm human dignity. Chinese generally view the fetus from a Confucian perspective: and it is not yet a human being.

As for embryo selection, in the �linguistic� section above I spoke about specific Chinese attitude toward eugenics: it is a science of verified social value. China desperately needs such a type of birth control, says Shi Weixing: about 800,000 ~ 1.2 million children with birth defects are born every year Shi Weixing. (2000) Biomedical Ethics (Shengwu yixue lunli xue). P. 212.. However, he adds that the practice of eugenics raises many ethical issues and should be properly regulated Ibid., p. 190..

Apparently, Shi Weixing considers �one family - one child� policy a form of eugenics. He writes that birth control policies are crucial to human society. In his rhetoric, the �precedent� of this policy seems to give a green light to other practices for cultivating a healthy society.

If abortion associated with serious fetal defects is necessary and ethical, writes Shi Weixing, then the sex selection that is still common in China is completely unacceptable. This is by no means a private affair of the family, but of the whole society. According to 2005 data, the national average sex ratio of birth population was 116.86: 100 (male:female); in five provinces across the country it was even higher - 130:100, with the record-breaking 135.64:100 in Hainan Province Shi Weixing. (2000) Biomedical Ethics (Shengwu yixue lunli xue). P. 214.. According to World Economic Forum's Global Gender Gap Report (2018), the situation is now slightly better with 115:100 sex ratio, that, however, makes China one of the top-3 countries in the world with such a big imbalance (along with Armenia and Azerbaijan). According to official figures, there are 33 million more men than women in the country Zhou, V. Inkstone Index: China's Gender Imbalance. URL: [https://www.inkstonenews.com/society/inkstone-index-china-has-worlds-largest-gender-imbalance/article/3000518]..