Euthanasia and Physician-Assisted Suicide: Murder or Mercy?

Introduction Chinese medicine has a history of at least 2,000 years. The first explicit literature on medical ethics did not appear until the seventh century when a physician named Sun Simiao wrote a famous treatise titled "On the Absolute Sincerity of Great Gold.1 In this treatise, later called The Chinese Hippocratic Oath, Sun Simiao required the physician to develop first a sense of compassion and piety, and then to make a commitment to try to save every living creature, to treat every patient on equal grounds, and to avoid seeking wealth because of his expertise. Traditional Chinese medical ethics is the application of Confucianism in the field of medical care.

Confucian ethics is a form of virtue ethics with a strong deontological basis. Its focus has been on the virtues that a moral agent should have and the ways they can be acquired. The starting point of this morality is the cultivation of one's character by becoming a person with compassion.

All the requisites that a physician should meet, and all the maxims that he or she should follow without regard to consequences, are heavenly principles. In premodern China, medical ethical issues were addressed only in the preface of medical texts. All maxims, exhortations, admonitions, and warnings were personal advice or suggestions of well-known and prestigious physicians of that time. These guidelines were based on the personal experience of noted physicians but were not professional codes in any sense.

There have never been medical professional organizations in traditional China, so codes would not have any binding power on physicians.2 Only on 1 January 1937 was "The Creed of Doctors" published by the Chinese Association of Doctors as the motto of modern medical practitioners in China.3 In 1949, after the founding of the People's Republic of China, the government cancelled the licensing system. Even though mistaken medical judgments were made after this time, the courts and lawyers were not allowed to become involved. Social control of medical practice relied mainly on regulations of health administrations and ideological education by the Communist Party Committee of Hospitals.

Medical personnel were required to read Mao's article titled "In Memory of Comrade Norman Bethune" and to generate criticism, and self-criticismaccording to Mao's teachings before and during the notorious Cultural Revolution. Medical ethics has become one of the most flourishing disciplines in the PeoPhysicians" in his work The Important Prescriptions Worth a Thousand Pieces of

This is an extract from a paper to be published in Transcultural Dimensions in Medical Ethics (Copyright University Publishing Group), coedited by Edmund D. Pellegrino, Patricia Mazzarella, and Piettro Corsi. Cambridge Quarterly of Healthcare Ethics (1993), 2, 69-76. Printed in the USA.

Copyright © 1993 Cambridge University Press 0963-1801/93 $5.00 + .00

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pie's Republic of China during the last decade. The current stage of Chinese medical ethics began with a conference on the philosophy of medicine, which was held in Canton in December 1979. At the plenary session of this conference, a report titled "Philosophical Issues of Medicine in the 1970V was made, part of which was devoted to medical ethics.4 After this conference the discussion of medical ethics focused on two issues: the concept of death and euthanasia and the delivery of medical care without discrimination.

5 Before the publicity of two legal cases, one on active euthanasia and the other on artificial insemination by donor (AID),6 the discussion was circumscribed by academic and professional circles. These circles were comprised of physicians, philosophers, and healthcare administrators who were publishing in specialized journals and attending conferences or colloquia on philosophy of medicine or medical ethics. After the publicity about the cases, medical ethics drew attention from lawyers, journalists, policymakers, legislators, and the public.

For example, after broadcasting divergent opinions about the first legal case on active euthanasia in a dialogue aired on a popular program called "Half Hour at Noon/' Central People's Broadcasting Station received more than 1,000 letters from its audience all over China; 85% of them favored some form of euthanasia, and 15% — including a school girl in the fifth grade of a primary school —were against any form of euthanasia. The widow of the late Premier Zhou Enlai, Mrs. Den Yinchao, took the time to write a letter to the station to support the discussion.

She said "A couple of years ago,. I wrote a living will to the effect that when I become terminally ill and medicine is no longer useful, the effort to save my life must not be made." In January 1989, another discussion of euthanasia was aired by the Central People's Broadcasting Station on a program called "English Service."

The First National Conference on Social, Ethical, and Legal Issues Relating to Euthanasia was held in Shanghai in June 1988; 112 physicians, medical scientists, nurses, philosophers, lawyers, and healthcare administrators attended. During this decade, one of the primary medical ethical Issues being addressed is euthanasia. There are two Chinese translations of the English word "euthanasia": anlesi, which means peaceful and happy dying, and wutongzhisi, which means painless killing. The first is more widely accepted.

On almost every point there has been dissent among physicians, philosophers, lawyers, and the public. At the Shanghai conference on euthanasia, only one thing was agreed on unanimously by all participants: the suggestion that the criterion for death of the person should be brain death. The other suggestion was that society ought to accept the rights of terminally ill patients to choose their way of dying and should encourage the practice of writing a living will. These recommendations were accepted by all but two participants.

However, there seems to be common assent that the following four kinds of patients fall within the category of those for whom euthanasia may be considered: the comatose, the terminally ill, seriously defective newborns, and very lowbirth weight Infants.

If the criterion of brain death is accepted and the irreversibly comatose can be defined as dead, they should not be excluded from the category.7 Can euthanasia be Identified as a special modality of death differentiated from natural death, accidental death, suicide, murder, and manslaughter? At the Shanghai conference, some participants characterized it in the following way:

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Under the condition of expressing her or his will orally or written, previously or presently, patients who are terminally ill and not incompetent [may reasonably request euthanasia]. If no living will is left, the withholding or withdrawal of useless, painful, or burdensome treatment or active measures to end his or her life painlessly may be taken out of compassion and a desire to be of assistance. [Such an act] is done out of respect for his or her dignity and right to choose a way of dying. If the person is incompetent, these procedures may not be done against his or her will.8

It was argued that this characterization can be applied to the seriously defective newborn and very low-birth weight infant with some modification. The problem in the case of euthanasia as characterized above is, What is the cause of death? Is it the action of withholding or withdrawing treatment, the action of ending life, or the disease process? Another problem is, How can the motive of this action be classified?

Was it done from compassion or from some selfish intention? Is euthanasia ethically justifiable? Most Chinese ethicists argue that the principles of beneficence, autonomy, and justice can be applied to justify euthanasia in certain circumstances. But behind the agreement there is a discrepancy in the argument. The holistic argument emphasizes the benefit euthanasia may bring to the whole society. The individualist argument is that we should respect the rights of the terminally ill to choose a way of dying that Is in their best interests.

If a terminally ill patient prefers to live as long as possible no matter how painful the life will be and there is no financial problem, to prevent access to the needed medical care, we should respect this choice. There have been, cases in which patients committed suicide by hanging themselves, or have cut an artery with a knife, or have jumped from a window after their request to withdraw treatment was refused. Physicians felt themselves to be In an embarrassing dilemma when faced with such cases.

Euthanasia can help us to avoid these tragic outcomes. In the case of seriously defective newborns and very low-birth weight Infants, euthanasia is intended to prevent an existence filled with suffering, at least in the current circumstances of China. It can be seen in letters from radio and television audiences who respond favorably to the idea of euthanasia. One elderly person wrote, "I don't want to die in a painful way/' Another person, who had had the experience of caring for a terminally ill relative wrote, "I have no heart to see my kin dying in such a way."

The main objections brought forth against euthanasia are: 1) psychological —when people are close to death, they often have a stronger will to continue life; 2) ethical —the heavenly principle of medical ethics prohibits a physician from doing anything that might bring the patient closer to death; 3) social — any form of euthanasia can be misused as a disguise for murder; and 4) medical — euthanasia will hinder the development of medicine. Does euthanasia violate existing Chinese law? Most Chinese lawyers give a positive answer.

Euthanasia violates the existing Chinese martial law, criminal law, and civil law. In the official explanation of criminal law, there are two factors that are very important in judging if an action constitutes a murder: motive — whether or not the agent intends the death of the innocent victim—and effect —whether

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the action is the cause of the victim's death. In the case of euthanasia, the motive of the agent and the effect of the intervening action are the same as in the case of murder. However, some have suggested that it is possible to change the current explanation by applying the principle of double effect. Is euthanasia acceptable to the Chinese public? Surveys show that the percentage of respondents favoring active euthanasia and passive euthanasia is higher than we expected. In a survey my colleagues and I made in 1985,9 four actual cases were described: a newborn with serious heart disease (cardianastorophe, angioplany, hypoplastic left heart, ventricular septal defect, auricular septal defect), a 1-montR-dId female baby with microencephaly, an irreversibly comatose patient, and a dying cancer patient with intractable pain.

The percentage favoring euthanasia was 14.7%, 62.4%, 37.1%, and 39.4%, respectively. In the first case, 42.9% of the respondents favored the parents as final decisionmakers, whereas 33.5% favored a committee, and only 17.1% thought that the physician should make the decision alone. In the second case, 58.5% of the respondents held the view that even though a 1-month-old baby is a person, it is permissible to take his or her life if the quality of that life is very low.

Another survey showed that 37.09% of respondents favored euthanasia and 46.02% thought that it should be done by specialized workers. In this survey, 54.97% thought that the decision should be made by consultation between physician and family, 26.82% favored the patient as decisionmaker, and 8.94% favored the physician. Attitudes towards euthanasia reflected professional, educational, and age differences. Respondents who were medical personnel or engaged in other intellectual pursuits, well educated, or younger held a more favorable attitude toward euthanasia.10 Discussion These surveys show that more and more Chinese medical personnel and laypersons take quality of life into account when considering euthanasia.

The respondents reflected a balance of different values. The principle of respect for the sanctity of life embodied in the practice of making every effort to prolong life no matter what the cost and the principle of paternalism embodied in the practice of decision making by the physician without informed consent both seem to be weakened.

A story of a peasant who rescued a diseased pig was published on the first page of People's Daily and praised as a model of moral action. Another similar story was that of a train that made an unscheduled stop at a station so that an ill passenger could be treated. A change in the focus of morality has taken place since the Cultural Revolution. Euthanasia, especially active euthanasia in general and that practiced in the case of seriously defective newborns and low-birthweight infants, seems to be getting increased support from professionals and the general public in China.

The percentage of respondents from different social strata who support euthanasia is very high in the surveys made in various locations by different kinds of medical professionals working in various institutes. Most lawyers maintain the view that euthanasia, especially active euthanasia, violates existing Chinese laws. Most physicians and ethicists, however, seem not to reject active euthanasia. In journals and newspapers or on the radio, those who have come forward to argue against euthanasia are in the minority. Is there a silent majority who are against euthanasia? Probably not. Although the audience who wrote to the radio station might be the segment of the public who were interested in and sensitive to this 72

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issue, in many surveys the respondents were randomly chosen. For the survey I made in 1985, when euthanasia was not the hot topic it is now, respondents were chosen at random, and many of those selected were hearing the term, "euthanasia" for the first time. However, would those who favored euthanasia in the survey actually withhold or withdraw the treatment? Perhaps not. Certainly the following two factors would influence this decision. Economic. If the cost of medical care were to be paid by the patients, they and their families would be more likely to ask the physician to withhold or withdraw treatment.

If the patients were receiving free medical care, they and their families would be more likely to ask the physician to continue the treatment. Cultural. There have been cases in which the patient, his or her children, and the physician all said that the treatment was meaningless and suggested withdrawing it, but nobody took action. The children feared that other relatives would blame them for violating the principle of filial piety, and the physician feared accusations of malpractice or murder.

The attitude toward newborns and the elderly in this respect is different from, that in the United States. It is very difficult to withdraw treatment from the elderly person who is terminally ill, whereas treatment for seriously defective newborns and very low-birth weight infants is easily stopped. Because some parents give up on babies, even if they have only a harelip or seal fin deformity, we feel it is necessary to take measures to protect these infants. Protection is necessary for several reasons: Historical. Infanticide has been a traditional, practice in China. As early as 300 B.C., an ancient philosopher Han, Fei criticized female infanticide in the book Han Fei Zi, compiled by his disciples.

Economic. It is considered an, unbearable burden for a young couple to raise a seriously defective newborn or a very low-birth weight infant. Cultural. Newborns with a serious deformity were considered monsters and labeled "monster fetuses." These babies were not accepted by the community. Political. Under the policy of "one couple, one child," the parents tend to withdraw treatment from, a defective child so that the one child they may raise will be healthy.

In making a medical decision, the patient's interest and the interest of the patient's whole family are considered. In the case of the terminally ill, a patient with a higher salary and free medical care may prefer lingering in bed as long as possible, even though he or she wishes to die more peacefully and painlessly. In some cases, the patient may refuse to be informed and ask the physician to provide the information only to her or his spouse or children. Chinese patients traditionally do not make a strong effort to exercise the right to self-determination. Recently, however, some changes have taken place.

For example, the cases of terminally ill persons committing suicide after their request for withdrawal of treatment has been refused by their physicians show the awakening of the sense of autonomy. In this negative way, these desperate people claimed their right to self-determination. When there is a consensus on the medical decision after deliberate consideration and sufficient consultation between the patient, the family, and the physician, nobody intervenes if there is no financial or emotional conflict between them. Legal intervention in medical cases has no tradition. In the premodern period, the legal system was never involved in purely medical cases unless there was 73

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some suspicion of murder. During the Nationalist regime before 1949, physicians could be sued for malpractice, but the Chinese preferred to resolve their disputes outside the legal system. They felt that presence in court was shameful. After the 1950s, the settlement of medical disputes was transferred to health administrations. But there are no laws or regulations concerning medical disputes.

In addition, health administrations are so busy that the treatment of medical disputes has been extremely unsatisfactory, protecting the rights of neither patient nor physician. There have been cases in which relatives of the patient thought there was malpractice and, after becoming impatient with the slow and inefficient process of the health administration, went to the physician's office and attacked him physically to retaliate for the perceived injustice. Now, after the Cultural Revolution, the legal system is again involved in medical cases.

In Shanghai, there is a draft of a law concerning medical disputes that has been used experimentally in the legal system since 1988. Information on the result of this experiment has yet to be gathered. Both legal and ethical constraints on medical malpractice are underdeveloped in China. Since 1937, there has been no medical ethical code adopted by the Chinese Medical Association. In December 1988, the Chinese Ministry of Health drew up and promulgated a brief ethical code for medical personnel.

This code instructs medical personnel to "heal the wounds, rescue the dying, practice socialist humanitarianism," to "respect the patient's personality and his or her rights, treat all equally without discrimination," and to "respect the patient's privacy and to keep his or her confidence."11 Contemporary Chinese medical ethics has been developed in a country with a backward economy, a power-centralized political system, a population of one billion — one quarter of whom are illiterate and semi-illiterate — and a cultural tradition of thousands of years.

Chinese culture was shaped by the Three Teachings: Confucianism, Taoism, and Buddhism. Moral intuition and moral attitudes towards medical ethical issues and resolution of ethical dilemmas (at lay, professional, and societal levels) are affected by the longstanding, entrenched traditional values and the current dominant ideology.

The Three Teachings provide a unique organic worldview as a conceptual framework for the explanation and treatment of disease and a unique ethics with strong virtue-oriented and deontologlcal focus for dealing with the relationship between physicians and patients. These characteristics can best be understood in terms of Chinese culture by noting the unique Influence of Chinese culture upon contemporary medical ethics. In approximately the third century B.C., the great Confucianist Xun Kuang and the great legalist Han Fei were said to have argued that a human being begins with birth and ends with death. Since then, this view has become a conventional Chinese view. T

raditionally, the mourning period after a person's death continued for 7 weeks, but a dead fetus was never mourned. There Is a contradiction, however, to this traditional belief and consequent practice: when a baby is born, it is considered to be 1 year old. One explanation is that the Chinese emphasize the continuity between the fetus before birth and the baby after birth, but they do not necessarily hold that the fetus is a human being or a person.

When an abortion, spontaneous or induced, took place, the Chinese never said that a person or human being died. One reason for this view may be, perhaps, that the premodern Chinese had never developed an understanding of fetal life and development; even contemporary Chinese know very little about this process. What then Is life or death? Both Confucianists and Taoists see life as the coordi74

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nation of Qi (vital force) and death as the dispersion of Qi. The life of a person is the product of interaction between Yang (light Qi) and Yin (heavy Qi). Yang comes from. Heaven and father, and Yin from. Earth and mother. After the death of a person, Yang is returned to Heaven and Yin to Earth. So a person comes from, nature and returns to it. The least intelligent being, an amoeba, and the most intelligent being, a human being, each consists of Qi, and they are integral parts of a continuum, — a chain of beings that is never broken because nothing is outside of it.

Birth and death are two of the greatest events in human life because each, person only has one chance to be born and one chance to die. So the Chinese have a grand ceremony to celebrate these occasions. Birth, and death are called "red and white happy events." Birth is nothing but a new form of Qi, and so is death. For Confucianism,, what is valued is not human life itself, but living in an ideal way. The great historian Sima Qian said that every person, must die, and that a person's death is as heavy as the Tai Mountains and as light as a feather of the wild goose.

Confucius once said: A man of humanity will never seek to live at the expense of injuring humanity. He would rather sacrifice his life in order to realize humanity. 12 What is valued is a meaningful, not a meaningless life. The meaning of life for Confucianists is found, by following Confucian ethical, principles, which, teach people to be human— to be worthy members of the universal family. Moreover, for Confucianists, to live or to die is not a thing that can be controlled by human beings. Confucius once said: Life and death are the chance of Heaven; wealth, and honor depend on Heaven.13 For Taoists, one school, emphasizes the preserving of life by means of proper breathing, exercise, diet, sex, and appropriate medicines.

What Taoists want to preserve is a natural existence that will maintain a harmony or balance of Yin and Yang within the human body and between it and the universe. For the major Taoists, an ideal spiritual sphere for a human being is to transcend all distinctions or dichotomies, including life and death. Why should we be pleasant at birth and sad at death? And the great Taoist Zhuang Zhou once said that the most unhappy thing in, the world is mind death, because then a person becomes a walking corpse.

For Chinese Buddhists, the highest goal a person, can reach is Nirvana, in which life and death are transcended. In this state, all things in, their own nature are truly experienced as unreal and void. To reach Nirvana and save all forms of life, it is necessary for a person to get rid of karmas and return to the emptiness of original mind. As for suffering, Confucianists see it as the tempering of one's moral character. As Mencius said: When Heaven is about to confer a great responsibility on any man, it will exercise his mind with sufferings, subject his sinews and bones to hard work, expose his body to hunger, put him to poverty, place obsta75

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cles in the paths of his deeds, so as to stimulate his mind, harden his nature, and improve wherever he is incompetent.14

The Three Teachings have developed a doctrine to help the Chinese release themselves from sufferings. There are two elements in this doctrine. The one is "nonaction" (Wu Wei), which does not mean "do nothing/' but rather do nothing unnaturally or beyond nature. One source of suffering is what one desires to be rather than what nature permits. The other is attachment. One can pursue something, seek for something, but must not be attached to it. If one is non- or de-attached and something that has been gained is lost, it will not cause any sufferings to her or him. When a patient is terminally ill, why do we prolong his or her dying unnaturally?

Why do we attach to this existence, which is going to cease naturally? Let nature take its course. For Chinese Buddhists especially, suffering is caused by failing to know the truth that all things in the universe are nothing more than the apparent phenomena of mental activities; by keeping the mind in a state of emptiness and calmness, all suffering can be avoided.

The Chinese conceptions of life, death, and suffering have led them to the following attitude: Treasure human life but do not attach to it. The suffering experienced by the Chinese has been, perhaps, much greater than that experienced by any other nation, but by this attitude, the Chinese have been able to cope with the burden of death and release themselves from it.

Notes 1. Sun S. The Important Prescriptions Worth a Thousand Pieces of Gold. Printed in the period of Wanli's reign, Ming Dynasty. Volume 1:9-11. 2. Qiu RZ. Medicine — the art of humaneness: on the ethics of traditional Chinese medicine. The Journal of Medicine and Philosophy 1988; 13:277-300. 3. Wang J. The new document of medical ethics. Chinese Journal of Medicine 1944:3039-40. 4. Qiu RZ. Philosophy of medicine in the 1970's. In: Studies in Philosophy of Science. Beijing: The Knowledge Press, 1982:281-331. 5. See note 4. Qiu. 1982:281-331. 6. Sass HM, ed. Case Studies for Bioethical Diagnosis. Ruhr, Germany: Universitat Bochum, Zentrum fur Medizinnishe Ethik, 1989:1. 7.

See note 4. Qiu. 1982:281-331. 8. See note 4. Qiu. 1982:281-331. 9. Qiu RZ. The concept of death and euthanasia. Medicine and Philosophy 1985; 1:77-9. 10. Guo QX. A survey on euthanasia. Medicine and Philosophy 1988;6:34-6. 11. People's Daily 1988 Dec. 21:1. See also Chinese Hospital Management 1989;9(3):5. 12. Chan WT. A Source Book on Chinese Philosophy. Princeton, New Jersey: Princeton University Press, 1963:43. 13. See note 12. Chan. 1963. 14. See note 12. Chan. 1963.