Medical Professionalism in China and the United States

Articles from The Journal of Clinical Ethics are copyrighted, and may not be reproduced, sold, or exploited for any commercial purpose without the express written consent of The Journal of Clinical Ethics. 48

The Journal of Clinical Ethics

Spring 2015

Jing-Bao Nie, Kirk L. Smith, Yali Cong, Linying Hu, and Joseph D. Tucker, “Medical Professionalism in China and the United States: A Transcultural Interpretation,” The Journal of Clinical Ethics 26, no. 1 (Spring 2015): 40-7.

Medical Professionalism in China and the United States: A Transcultural Interpretation Jing-Bao Nie, Kirk L. Smith, Yali Cong, Linying Hu, and Joseph D. Tucker

ABSTRACT As in other societies, medical professionalism in the Peoples’ Republic of China has been rapidly evolving. One of the major events in this process was the endorsement in 2005 of the document, “Medical Professionalism in the New Millennium: A Physician Charter,” by the Chinese Medical Doctor Association (hereafter, the Charter).1 More recently, a national survey, the first on such a large scale, was conducted on Chinese physicians’ attitudes toward the fundamental principles and core commitments put forward in the Charter. Based on empirical findings from that study and comparing them to the published results of a similar American survey, the authors offer an in-depth interpretation of significant cross-cultural differences and important transcultural commonalities. The broader historical, socio-economic, and ethical issues relating to salient Chinese cultural practices such as family consent, familism (the custom of deferring decisions to family members), and the withholding of medical information, as well as controversial topics such as not respecting patients’ autonomy, are

examined. The Chinese Survey found that Chinese physicians supported the principles of the Charter in general. Here we argue that Chinese culture and traditional medical ethics are broadly compatible with the moral commitments demanded by modern medical professionalism. Methodologically and theoretically—recognizing the problems inherent in the hoary but still popular habit of dichotomizing cultures and in relativism—a transcultural approach is adopted that gives greater (due) weight to the internal moral diversity present within every culture, the common ground shared by different cultures, and the primacy of morality. Genuine crosscultural dialogue, including a constructive Chinese-American dialogue in the area of medical professionalism, is not only possible, but necessary. INTRODUCTION In recent decades, medical professionalism has been developed as a global response to a range of challenges facing contemporary medicine. One sig-

Jing-Bao Nie, BMed, MMed, PhD, is an Associate Professor at the Bioethics Centre, Division of Health Sciences at the University of Otago, Dunedin, New Zealand; and Adjunct Professor at the Institute for the Medical Humanities, Peking University Health Sciences Center, Beijing, People’s Republic of China, [email protected]. Kirk L. Smith, MD, PhD, is a Distinguished Visiting Professor at the Institute for the Medical Humanities, Peking University; and Adjunct Associate Professor in the Division of Health Promotion and Behavioral Sciences at the University of Texas Health Science Center Houston, School of Public Health, Houston, Texas. Yali Cong, PhD, is a Professor of Medical Ethics at Peking University Health Science Center and is the Director of the Department of Medical Humanities at the Peking University Health Science Center. Linying Hu, PhD, is an Associate Professor in Division of Medical Ethics at the Institute for Medical Humanities, Peking University. Joseph D. Tucker, MD, PhD, is Director of UNC Project-China, Assistant Professor of Medicine at the University of North Carolina at Chapel Hill, and a Research Associate at the International Diagnostics Centre in London. ©2015 by The Journal of Clinical Ethics. All rights reserved.

Articles from The Journal of Clinical Ethics are copyrighted, and may not be reproduced, sold, or exploited for any commercial purpose without the express written consent of The Journal of Clinical Ethics. Volume 26, Number 1 nificant outgrowth of that response is the document “Medical Professionalism in the New Millennium: A Physician Charter”2 (hereafter, the Charter), published in 2002 as a collaborative endeavor of the American Board of Internal Medicine (ABIM) Foundation, the American College of Physicians Foundation, and the European Federation of Internal Medicine. The Charter articulates—and seeks international agreement on—the moral commitments of physicians, laying out three fundamental principles—patients’ welfare, patients’ autonomy, and social justice—and 10 corollary commitments to competence, honesty, confidentiality, propriety, quality, access, justice, knowledge, trust, and selfregulation. The Charter aims to standardize the obligations of medical professionals to patients and to society and underscores the transcultural status of physicians who, while “embedded in diverse cultures and national traditions,” “share the role of healers.” Thus, the core principles and commitments of medical professionalism are “applicable to different cultures and political systems.” Given the global ambitions of the Charter, it is worth considering the attitudes of medical professionals in various national traditions to see how its principles fare when applied in circumstances other than the mainly Western cultural environment in which the document was developed. One non-Western nation that has given serious attention to medical professionalism is the Peoples’ Republic of China, where physicians face major challenges as a result of rapid changes in Chinese society over the past 35 years.3 Recently, a national survey was conducted in China to elicit and quantify Chinese physicians’ attitudes toward the principles enunciated in the Charter, (hereafter, the Chinese Survey).4 The results reveal that Chinese physicians support some of the core principles laid out in the Charter,” but not others, and confirm the persistence of attitudes that are characteristic of traditional Chinese culture, such as paternalistic attitudes by doctors toward their patients and familism, an ancient cultural practice that ranks family consensus above individual choice. The Chinese Survey was partly modeled on a survey of U.S. physicians developed by Eric G. Campbell and colleagues (hereafter, the American Survey).5 The two surveys provide a unique opportunity to investigate medical professionalism in China and in the United States, two large societies that, superficially at least, seem worlds apart. In the present article, we—a group of American and Chinese scholars and physicians—compare the empirical findings of the Chinese Survey and the American Survey in order to acknowledge not only


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apparent cross-cultural differences, but also significant transcultural similarities. We base our analyses on a common appreciation of the main issues at stake, benefiting from familiarity with our own respective traditions, as well as the study we have made of the corresponding culture—China or the U.S., as the case may be—and subsequent discussion and interaction in the course of preparing this article. In interpreting the surveys’ findings to each other, suggesting possible reasons for results and discussing their meaning, we have consciously striven to develop a transcultural understanding of Chinese and U.S. attitudes toward medical professionalism, at the same time being wary of creating misrepresentations and false dichotomies or oversimplifying cultural traditions. We do so by (1) making the existence of these two more-or-less head-tohead comparable surveys better known, (2) laying out survey results from a cross-country comparative perspective, and (3) presenting a transcultural paradigm that is useful in explaining and interpreting differences and similarities in the two national cohorts’ survey results. A TRANSCULTURAL APPROACH In comparing Western and non-Western cultures, such as the U.S. and China, one pervasive approach has been to set one’s own culture against its presumed opposite—“us” and “them,” East versus West. This is an ancient habit, already notable in Aristotle’s and Herodotus’s comparative characterization of Greeks and the non-Greek peoples of Egypt and Asia. Dichotomizing East and West is the intellectual foundation of Orientalism, which has so powerfully shaped modern Occidental attitudes toward the Orient.6 Until very recently, the discipline of anthropology has reinforced this approach to the study of non-Western cultures, and a number of myths and stereotypes, such as the reification of a “communitarian or collectivist China” versus the “individualistic West,” still enjoy wide circulation.7 The tendency to dichotomize cultures also dominates the field of cross-cultural and comparative bioethics, a good example being an influential article by two prominent American sociologists and bioethicists, Renée Fox and Judith Swazey.8 Fox and Swazey wrote of the “Chinese-ness” of medical ethics in China and the “American-ness” of bioethics in the U.S., characterizing them in terms of communitarianism versus rugged individualism. According to Fox and Swazey, Chinese “medical morality” highlights a spirit of self-sacrifice and self-cultivation, a lofty sense of responsibility, modesty, self-



control, and devotion to family and nation. The Chinese way of thinking embodies holism, “twolegged dualism” (that always involves a chain of dualities: yin-yang, self and others, the individual and society, preventive and curative medicine, modern Western and traditional Chinese medicine, and so forth), the principle of dynamic complementarity, pragmatism, and collectivism. On the other hand, American bioethics and its intellectual assumptions are said to emphasize a narrowly gauged individualism and the language of rights, and are marked by a contrarian outlook, positivism, objectivism, materialism, rationalism, absolutism, and secularism. For Fox and Swazey, Chinese medical morality is the “radical other” of American bioethics. This American account of medical ethics in China was published 30 years ago. Of course, since then China and the U.S. have experienced unprecedented, large-scale exchanges and intimate interactions between people, goods, and ideas. Today, observers in the West know more “facts” about medical ethics in China, and there is an increasing body of literature on the subject in the English language. Nevertheless, the specter of the dichotomizing approach exemplified by the report by Fox and Swazey still haunts the public mind and lingers in academic circles when comparing China and the U.S., East and West.9 An alternative approach is needed to more adequately understand cross-cultural differences as well as transcultural similarities. In an earlier investigation of medical ethics in the Chinese sociocultural context from a Chinese-Western comparative perspective, one of us (J-BN) has put forward an “interpretative” or “transcultural” approach to bioethics.10 The major features of this theoretical and methodological paradigm are: • Overcoming stereotypes and appreciating the complexity of cultural differences, • Highlighting the internal plurality and diversity found within every culture, • Focusing not only on cross-cultural differences, but also on transcultural similarities or commonalities, • Promoting a genuine and deeper dialogue between different cultures, and • Upholding the necessity of moral judgments and the primacy of morality over culture. This alternative transcultural approach resists belief in an inevitable clash of cultures, the endorsement of the tyranny of cultural practices and norms over ethics or morality, and various versions of cultural and ethical relativism.

Spring 2015 To compare results of the American Survey and the Chinese Survey reports using our transcultural interpretation, we begin by focusing on its most salient features: (1) the extent to which the surveys reveal that U.S. and Chinese physicians, both within and across national cohorts, largely approve the principles in the Charter, and (2) the nonetheless significant divergence between U.S. and Chinese physicians, especially in their attitudes towards autonomy and the nature of the patient-physician relationship. Detailed statistical comparisons and discussion follow below, but at first blush these saliencies invite two distinct interpretations, one more consistent with Fox and Swazey’s analysis, the other more aligned with our transcultural approach. A transcultural interpretation focuses not only on differences but also agreements between cultures; it is challenged to account for divergence, in the present case, that of U.S. and Chinese attitudes toward certain principles in the Charter. A competing interpretation, consistent with various versions of cultural and ethical relativism, takes divergence as proof of the culturally embedded nature of values, the “rightness” of which cannot be decided except from within the context of the respective culture. An example that will be discussed further below (under the section on autonomy) is the practice, common among Chinese doctors, of deferring controversial treatment decisions to senior physicians and/or hospital administrators. For approaches that emphasize indigenous values, this practice could be deemed a cultural norm, as acceptable in its context as the Western norm of deferring such decisions to patients and family members. For those who adopt such an approach, the challenge becomes how to explain consensus between cultures, in this instance, the convergence of U.S. and Chinese physicians’ attitudes around principles in the Charter. Taking the latter approach first, such an explanation might begin by noting that the principles upheld in the Charter reflect values already established in the U.S. and enjoying the West’s imprimatur. Therefore, a relativist might argue, it is only natural that American physicians would approve of them, having already been schooled to their propriety by custom and indoctrination. Chinese physicians, coming from a different tradition, are not so quick in their endorsement, and their divergence from Western norms underscores the incommensurability of the two value systems. Indeed, one might be tempted to interpret the empirical finding that Chinese physicians largely agree with the principles in the Charter as an indictment of the West’s success in imposing its values on the East, a charge sup-

Articles from The Journal of Clinical Ethics are copyrighted, and may not be reproduced, sold, or exploited for any commercial purpose without the express written consent of The Journal of Clinical Ethics. Volume 26, Number 1 ported by the Chinese study’s finding that physicians who received all or part of their training in the West are most likely to approve the Charter in detail. This explanation lends itself to charges of cultural imperialism, a debate we are keen to avoid, less because of its complications, than that we think it errant. For while none can dispute that the West has often been arrogant and even violent in imposing its values on other cultures, in the case of U.S. and Chinese medical practice, we believe that professional obligations and the primacy of morality can be defended on grounds that transcend cultural traditions, and are often already apparent in those traditions, as we intend to demonstrate in our discussion of the survey results below. AUTONOMY VERSUS FAMILISM In the questionnaire used in the Chinese Survey, a hypothetical case study presented an older male patient with lung cancer whose condition deteriorates such that he is hospitalized, and his physician strongly urges a ventilator. Two scenarios are offered: (1) The patient is conscious, and after being fully informed of the invasive intervention, refuses it; his family, however, insists that the ventilator be used. (2) The patient loses consciousness and, when asked, the family declines use of the ventilator. For each of these scenarios, respondents were given options: either to respect the patient’s wishes, defer to the family, or act on the guidance of senior medical and hospital administrators. In response to the first scenario, 35.4 percent of Chinese physicians responded that the physician should “follow the patient’s family’s request and use the respiratory machine,” while virtually the same number (35.8 percent) agreed that the physician should “report and act on the advice of their clinical superior or the hospital leader.” Only 28.8 percent responded that the physician should “respect the patient’s decision and not use the respiratory machine.” In response to the second scenario, 64.9 percent of respondents believed that the physician should “follow the patient’s family’s request not to use the respirator”; in addition, 35.1 percent agreed that the physician should “report to their clinical superior or the hospital leader and listen to them.” As the Chinese investigators emphasize in their report, these empirical findings highlight the importance of family consensus or familism in deciding issues critical to the welfare of the patient’s family; in the case of the above, the treatment of a severely ill family member. This feature of Chinese culture contrasts with the situation in the U.S. and most


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other Western countries, where family members often play a role in medical decision making, but their role is strictly limited and defined; for example, there is a clear hierarchy of influence (for example, a spouse has precedence over a child, a child has precedence over a cousin, et cetera) and, however adamant family members’ determinations, the patient’s wishes have overriding authority. In China, by contrast, consent forms for medical procedures and interventions such as surgery are often signed by relatives rather than by patients themselves, even when they are competent to do so, and legislation and social polices, including Zhiye Yishi Fa (the Practicing Physicians Law), condone this practice.11 Consistent with the tradition of familism (a social structure akin to tribalism and characteristic of many early societies, but in China given concrete conceptual status by Confucius, who conceived it as the basic unit of civilization and whose authority persisted well into modern times), the Chinese Survey reveals that many physicians are inclined to allow family consensus—which may or may not give preeminence to a patient’s wishes—to determine medical decisions. Indeed, it has been suggested that, sociologically and culturally speaking, the Chinese physician-patient relationship is more accurately characterized as a “doctor-family-patient” relationship, with the family in the middle.12 Familism is, on its face, antithetical to the principle of autonomy, which holds that individuals should be allowed to determine the course of their own life. This principle was prominently articulated by Immanuel Kant,13 whose critique has become central to Western, and now transcultural, ethics. In brief, this critique holds that if one is determined to behave ethically, then certain conditions must be met as a logical necessity of that decision, the foremost being that one recognizes the right of others to act autonomously, that is, to be moral agents in their own right and to make decisions freely. The power of Kant’s critique derives from its logic: if autonomy is a necessary condition of ethics per se, then the moral system founded on it transcends tradition, custom, habit, or culture. It is a universal system, and any rational system, insofar as it purports to be ethical, must adopt the principles fundamental to it. The details of Kant’s ethical system, in particular the rigidity with which he applied its logic to realworld dilemmas, has been much criticized; however, the method he described for analyzing the validity of global principles remains largely intact. That analysis entered the medical mainstream with the rise of bioethics and the introduction of the principles approach to Western medical discussions (for



example, “The Belmont Report”14). Bioethics’ influence on those discussions is evident in that the authors of the Charter adopted a principles-based format, and Kant’s influence is evident in the priority given to autonomy as one of the three ruling principles, along with the welfare of patients and social justice. That document’s debt to Kant is also evident in the global claim it makes for the principles of medical professionalism. To the question, Why this morality?, the Charter can answer, Because these are the principles necessary to ethical medical practice per se. This position is of critical importance to the goal of the Charter, as it underscores medical professionals as transcultural figures whose obligations remain essentially the same, whatever the context. To illustrate our transcultural approach, we begin by applying it to the cultural tradition that inspired the Charter, specifically, the Kantian critique of ethics that influenced its principle-based format. It is logically consistent to claim that, insofar as human beings choose to behave ethically, then moral agents must be allowed autonomy in deciding their own ends. While this may seem to restate Kant’s original position, this is not the case, because there is no logical reason to suppose that moral agency must be invested in individuals. In some contexts, individuals are singled out as moral agents—the entities exercising decision-making authority—while, at other times, collective entities (for example, the family unit) may better exercise this authority. The conditions affecting which entities stand as moral agents include cultural influences and traditions. For example, in the West, with its tradition and culture of individualism, the individual most frequently acts as decision maker; whereas, in China, with its tradition of familism, the family often exercises that role. However, families in the U.S. and individuals in China need not be bound by these traditions, and they often act in ways that show they are not. In Western cultures, in the context of particular families, decisions are frequently made, all or in part, by family consensus. Indeed, the role of the family as an essential social institution and nexus of moral values is deeply rooted in Western societies, including the U.S., where significant religious, political, and moral traditions emphasize the role of family as crucial for a healthy society and the flourishing of individuals. Specific to medicine, bioethicists have long recognized the normative role of the family; for example, in resolving the ethical challenges involved in genetic testing, palliative care, and care of the chroni-

Spring 2015 cally ill and the elderly.15 Likewise, in contra-stereotypical fashion, treatment decisions in China are often made by the affected individual, sometimes even despite family pressure. From a culturalist perspective, one may argue that Kant’s moral philosophy, such as the notion of autonomous self and universalism, is totally alien to Chinese culture. This widely assumed viewpoint can nevertheless be another stereotype of Chinese culture and moral traditions. Classical Confucian ethics, established in the formative period of Chinese culture, represents an ancient epoch of enlightenment that is fundamentally compatible with Kant’s moral outlook, as an insightful study by a German philosopher and sinologist explains.16 Different from the dominant Western paradigm of Chinese studies, which often treat Chinese cultures as the “radical other” of the West, and based on a careful reading and creative interpretation of primary Chinese sources, such notions as autonomous self, universal moral principles, and critical moral reflection were long developed in classical Confucianism.17 The strength of this nuanced transcultural approach is that it recognizes the necessity of autonomy, such that one can judge when autonomy is being violated, while allowing discretion and attention to the circumstances in which that judgment is made. Thus, one can hold it to be morally acceptable, in justified circumstances, to defer to the culture of familism while holding it unacceptable to allow medical staff or hospital administrators to make treatment decisions against the wishes of the patient, or the family. This is because, whether they are enacted by the individual patient or the family as a unit, treatment decisions must be made by those who bear the immediate consequences of the decision, that is, by the directly affected moral agents whose autonomy would otherwise be violated. Such a stand is useful in navigating tensions that could be engendered by, for example, insisting that individuals in the U.S. make decisions that they prefer to defer to the family, or, in China, acceding to familism when the alleged consensus does not include the affected patient’s own wishes.18 Also, Chinese familism may face serious ethical problems when parents refuse lifesaving medical treatment for an adolescent dependent.19 Accepting cultural influence does not require jettisoning transcultural principles, but it does call for skill in discriminating influences and testing their justification in order to uphold the necessity of moral judgments and the primacy of morality over culture. China’s major philosophical and religious

Articles from The Journal of Clinical Ethics are copyrighted, and may not be reproduced, sold, or exploited for any commercial purpose without the express written consent of The Journal of Clinical Ethics. Volume 26, Number 1 traditions other than Confucianism, notably Daoism and Buddhism, for example, challenge the pre-eminence of family as the basic social unit and the primacy of family values, and, in recent times, socialism and modernizing trends that have undermined familism. Marxist critics have offered powerful warnings against romanticizing the family as a social institution,20 and the family, as a social unit, has been implicated in abuses of power, such as negligence and domestic violence—physical, psychological, and sexual (practices such as female circumcision, which implicate all three, are especially suspect)—perpetrated against children, women, and elders, from which China is not exempt.21 The contemporary Chinese population control program, widely known as the “one-child” policy, has directly violated traditional Chinese norms regarding reproduction and the family.22 On the other hand, economic pressure has reinforced the family’s role in medical decisions: despite 60 years of socialism and progress toward universal healthcare, the bulk of medical costs in China are paid for by members of the patient’s family. Consequently, deferring to their wishes can be as much the product of financial incentive as respect for tradition. Moreover, as medical disputes and malpractice lawsuits in China have multiplied in recent years, initiated mainly by family members, physicians have found it expedient to defer to family consensus to avoid liability. It should be noted that U.S. doctors sometimes bow to family wishes to avoid lawsuits as well. A complication of our transcultural interpretation is that it requires careful weighing of these factors in determining what is moral: in the case of familism, when a family is properly respected as an autonomous moral agent, versus when that agency is compromised by external circumstances—for example, economic pressures or an abusive family dynamic—such that only the affected individual’s personal wishes merit respect. Discretion, then, must be the watchword of a nuanced transcultural paradigm. The downside is the burden this imposes on practitioners, who must be culturally receptive and attentive to family circumstances and to the factors that influence decision making, in order to engage, in a judicious manner, the patient and those to whom the patient looks for help in making decisions. Countering this added complication is the positive effect the approach has in enriching the physician-patient relationship, keeping it from devolving into an axiomatic transaction and maintaining focus on a comprehensive understanding of the patient’s circumstances and the maximization of care which, after all, should be the caregiver’s primary goal.


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TRUTH TELLING The Charter requires physicians to “ensure that patients are completely and honestly informed before the patient has consented to treatment and after treatment has occurred,” including prompt notice of injury and reporting of medical error “because failure to do so seriously compromises patient and societal trust.” In the American Survey, two questions were asked about honesty with patients: (1) “In the last three years, have you told a patient’s family member something about a medical issue that wasn’t true?” and (2) “In the last three years, have you withheld information that a patient or a patient’s family should have known about a medical issue?” Fewer than 1 percent of respondents answered “yes” to the first question, while 3 percent answered “yes” to the second, indicating that the overwhelming majority of U.S. respondents support a commitment to truth telling. Moreover, a very high proportion of American respondents—96 and 93 percent respectively—reported they believed that (1) “physicians should report all instances of significantly impaired or incompetent colleagues to the hospital, clinic, or other relevant authorities” and (2) that “physicians should report all significant medical errors they observe to the hospital, clinic, or other relevant authorities.” In China, by contrast, only slightly more than half (51 percent) of the physicians surveyed agreed that physicians should report significant medical accidents, errors, and incompetent colleagues to the relevant authorities. While the Chinese Survey did not include specific items on truth telling, it did query physicians’ attitudes about informed consent, and a large majority (82.8 percent) stated that informed consent is necessary. This seeming concurrence with Western practice, however, is mitigated by the finding that less than half (47.6 percent) of Chinese respondents agreed that patients have the right to know about their medical condition and treatment. Moreover, earlier research suggests that it is not uncommon for Chinese doctors to mislead patients by, for example, exaggerating the seriousness of a patient’s illness in order to protect the physician should an intervention prove ineffective, or to help patients and families to prepare for an adverse outcome. Such practices are rationalized as ensuring that “relations among doctors, family members, and patients remain harmonious.”23 Another divergence from Western norms involves the level of information disclosed about terminal illness. Whereas open and honest disclosure is standard practice in the U.S., in China medical



professionals routinely withhold information about terminal illness from patients, instead informing family members who, complicit with the physician, lie to patients about the seriousness of their condition. Employing a transcultural approach, rarely acknowledged features of Chinese attitudes toward truth telling can be brought to light to illuminate these practices.24 First, based on extensive review of primary historical materials, a long (albeit forgotten) Chinese tradition of truth telling about terminal illness—a tradition dating back at least 26 centuries—can be recovered. Contrary to what has been universally assumed both inside and outside China, the traditional practice and norm of Chinese culture and medical ethics was for physicians to disclose a diagnosis and prognosis of terminal illness truthfully and directly to patients. Second, this venerable Chinese tradition is especially remarkable when compared to the situation in the West, including the U.S., where concealing terminal illness was long the cultural norm—stipulated in ancient medical writings such as the Hippocratic canon and modern professional codes (such as the influential 1847 Code of Ethics of the American Medical Association25); indeed, disclosure did not become the norm in the West until the 1960s and later. Third, ironically, the present Chinese practice of nondisclosure is closely connected to the introduction of Western biomedicine into China in the late 19th century, when Chinese physicians not only adopted Western medical science, but also the West’s then-dominant norm of concealment. The history of truth telling in China is especially salient with respect to numerous recent surveys conducted throughout China, reporting that the great majority of Chinese patients want truthful information about their medical condition, even in terminal cases, as well as the finding that, when asked to imagine themselves as a patient, the vast majority of medical professionals and family members stated that they would prefer to know the truth.26 An historic shift is occurring in China, and it is essential to note the availability of an indigenous tradition, including the Confucian moral outlook, that mandates truthfulness as a basic ethical principle, to reform the contemporary practice of nondisclosure. Our point here is not to offer a detailed account on medical truth telling in China, which is available elsewhere,27 but to avoid interpreting the apparent Chinese-American divergences that may be found by an oversimplified and dichotomizing analysis of the two surveys. The historical and sociocultural features of medical truth telling in China,

Spring 2015 as very briefly summarized above, provide a fascinating case on the richness, internal plurality, dynamism, openness, primacy of morality, and possible transcultural common grounds of Chinese medical ethics, and even Chinese culture in general. As a result, it is not surprising that a different survey of Chinese physicians (which was not administered nationwide), on dealing with medical errors by senior colleagues, found that 120 of the 128 physicians surveyed (93.75 percent) indicated they should and will “surely” disclose such errors.28 THE WELFARE OF PATIENTS The Charter culminates efforts begun by Project Professionalism, an initiative undertaken by the ABIM 15 years prior to the publication of the Charter, in response to concerns about the interests motivating U.S. physicians—specifically, that corporate profits and personal gain were undermining the profession’s age-old commitment to putting patients’ interests first, which threatened to reduce the status of patients to commodities, rather than persons with an affliction.29 It is consistent with that concern that the first principle in the Charter is the “primacy of patient welfare,” and that its commitments are “based on a dedication to serving the interest of the patient.” The Chinese Survey reveals that Chinese physicians’ support for this basic principle of medical professionalism is relatively low: while 80.8 percent agreed that the physician-patient relationship (PPR) should be a “trust relationship based on professional altruism,” only 62.8 percent of respondents concurred with placing their patient’s welfare above their own private financial interests. This is a marked divergence from the attitude of their U.S. peers, 96 percent of whom endorse placing the patient’s welfare above private gain. Here it is worth noting that an explicit commitment to altruistic service is a long-standing ideal of Western medicine, already evident in the writings of ancient and Hellenistic medical writers, and that the formalization of the PPR as a relationship founded in trust can be traced to developments in the 13th century, when the discipline was established as a faculty within medieval universities. Medicine was then raised to the status of a learned profession, alongside theology and law. Ethical principles were crucial to this elevation, with doctors formally adopting, as a defining feature of the profession in the West, the obligation to put their patients’ interests first. The Charter is consistent with this history: its commitment to “maintaining trust by managing conflict of interest” reminds doctors

Articles from The Journal of Clinical Ethics are copyrighted, and may not be reproduced, sold, or exploited for any commercial purpose without the express written consent of The Journal of Clinical Ethics. Volume 26, Number 1 that they are held to a high moral standard and that the trust entailed in the PPR is supererogatory to the expectations of ordinary society. That this tradition remains viable in the minds of U.S. physicians is apparent in the finding, noted above, that American practitioners are nearly unanimous in concurring with “putting the patient’s welfare above the physician’s financial interests.” The relative absence of a comparable tradition in China—that is, a period of widespread reform like that of medieval Western medicine when professional standards were consciously elaborated and broadly enacted—may account for the relatively low percentage of Chinese physicians (again, 62.8 percent) who agreed with putting their patients’ interests above private gain. That explanation finds corroboration in the further finding that Chinese physicians are ambivalent as to their conception of what the PPR should be: while 80.8 percent said it ought to be altruistic and based on trust, 44.8 percent said it was an ordinary social relationship with no special obligations, and 27.6 said they think of it as a commercial activity. Nevertheless, the historical difference identified here should not be treated in an oversimplified way. As briefly presented in the section below on the traditional Chinese values of professional ethics of medicine, the commitment to the primacy of patients’ welfare has been expressed in the major medical ethics texts in Chinese history. It is thus very curious why this key commitment in traditional Chinese medical ethics has not been prominent among physicians in today’s China. Our hypothesis is that, while it has been expressed in the texts of traditional medical ethics, historically speaking, the commitment to the primacy of patients’ welfare has not been as well developed in theory and practice in China as in the West. Radical anti-traditionism, a pervasive intellectual and political current throughout 20th century China, has led to the profound depreciation of traditional values. Moreover, the development of a market economy in the past few decades has contributed to the rapid growth of materialism and the commercialization of healthcare. Testing our preliminary hypothesis will require a separate comparative study on the histories of medical professionalism in China and the West. SOCIAL JUSTICE The third fundamental principle endorsed by the Charter concerns social justice: “The medical profession must promote justice in the health care system, including the fair distribution of health care


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resources.” In both the Chinese Survey and the American Survey, physicians strongly supported the principle of social justice: U.S. respondents agreed that physicians should minimize disparities in healthcare due to race or gender (98 percent); advocate legislation extending healthcare coverage to all (86 percent); and provide necessary healthcare regardless of an ability to pay (93 percent). Chinese physicians agreed that physicians should provide medical support in remote areas (96 percent) and actively participate in healthcare reform (88.5 percent). Doctors in China are less disposed to promote equitable distribution of medical resources (71 percent) or provide necessary care regardless of an ability to pay (71.5 percent). These latter results are consistent with the finding that Chinese physicians are less likely than their U.S. peers to conceive of the PPR as an altruistic relationship (and are at odds with the socialist premise of the Chinese political system). To elucidate attitudes toward the utilization of resources in more detail, in both the American Survey and the Chinese Survey, physicians were asked to respond to the following hypothetical case: An otherwise healthy, long-term patient presents with his first episode of low back pain, lasting two days, with onset following some work around the house. He has no neuromuscular signs or symptoms. His doctor explains to him that his symptoms will likely resolve with rest and analgesia and doesn’t think any further testing is necessary at this stage. However, the patient is convinced that he has a herniated disc, and is quite insistent that he should have magnetic resonance imaging (MRI). The great majority of American physicians responded that they would avoid ordering an MRI, with only 36 percent agreeing to the request, or, alternatively, ordering an MRI but making it clear to the patient that they did so reluctantly. On the contrary, just over two-thirds (67.8 percent) of Chinese physicians opted to order an MRI scan at the request of the patient. Whether they would do so out of respect for the patient’s anxiety or some other reason is unclear (Chinese physicians often err on the side of caution in order to protect themselves from prosecution and/or violent reprisal by patients or patients’ families). In the U.S., the expressed reluctance to order an MRI may be related to incentives to provide cost-effective healthcare. In analyzing these findings, it is important to note that the issue of social justice with respect to medical professionalism is especially fraught with difficulty, as it often appears to pit physicians’ obligations to an individual patient against responsibili-



ties to society at large, as when healthcare is rationed to conserve public resources. The issue is further complicated by suspicion that such alleged responsibility may mask third-party interests, for example, health insurers’ interest in keeping pay outs low, or the state’s interest in controlling costs in the healthcare sector. Neither traditional medical ethics—with its focus on the individual patient and the dynamics of the PPR—nor bioethics—which began as a research ethics focused on the dynamics of experimentation involving human subjects—offer specific guidance on a doctor’s duty to social justice, although both have implications for that duty: medical ethics insofar as it obliges doctors to treat patients regardless of ability to pay, and bioethics insofar as the research at initial issue was federally sponsored and the expense borne by the public. Still, it is fair to say that the particular morality at stake in the practice of socially just medicine has been sharpened consequent to broad economic and sociopolitical changes that are relatively recent, most especially the commodification of healthcare, the increasing cost to the public purse, and the susceptibility of medical practice to corporate and market forces, trends that operate as much in China as in the U.S. Our object here is less to prescribe remedies for the social justice concerns raised by these trends than it is to mark the overlap of East and West with regard to the circumstances in which U.S. and Chinese physicians find themselves practicing. RESTORING PATIENT-PHYSICIAN TRUST We have highlighted important transcultural similarities between China and the U.S. But it is not our point that there are no significant sociocultural differences. Let us use patient-physician trust—another key and constant practical challenge in medical professionalism—as an example to illustrate differences and especially differences in similarities. To a considerable extent, many of the principles and commitments of medical professionalism, such as the primacy of patients’ welfare, patients’ autonomy, informed consent, and patients’ confidentiality, are geared to foster patient-physician trust—trust that is essential in providing high-quality healthcare and should drive the process of health systems reform. At the present time, there is a universal crisis in social trust, including that between patient and physician. It has been observed that patients’ trust in doctors has steadily declined in the U.S.30 The rapidly increasing incidence of conflict and violence affecting physicians in China indicates an alarming, large-scale trend that raises fundamental

Spring 2015 questions about patient-physician trust. According to one survey conducted in 2008,31 some 60 percent of Chinese physicians have personally experienced or have witnessed colleagues being subjected to work-related violence from patients or their relatives. According to another national survey carried out at 60 public hospitals across 10 provinces in 2008, more than half of all medical professionals have been assaulted verbally and almost one-third have been threatened on the job.32 The level of violence observed in China is markedly more common and more severe than that observed against medical professionals in other countries.33 Addressing the deteriorating patient-physician relationship, and rebuilding bonds of trust, will be one of the key tasks of medical professionalism in China. Such serious and widespread patient-physician mistrust is a problem far beyond interpersonal patient-physician relationship, and even the healthcare system itself, because it is a part of a much broader general crisis of social trust in contemporary Chinese society. It is also a matter of social justice because China is still in the process of establishing genuinely comprehensive and adequate healthcare coverage for all of its citizens, especially the poorest and those most in need. Nevertheless, the positive development of medical professionalism through, for instance, the improved integration of ethics, the humanities, and professional development into medical education, is essential to restore patient-physician trust in China and to revive “medicine as the art of humanity.”34 REVIVING TRADITIONAL CHINESE MEDICAL ETHICS In contrast to this transcultural approach, the culturalist perspective may argue against any global principles of medical professionalism from an ethical relativist standpoint, a position we have addressed above. Appealing to cultural differences, it may assert that the global principles of contemporary medical professionalism are alien to China, and to traditional Chinese norms and practices in particular. There are indigenous Chinese materials that support the fundamental principles and core commitments of medical professionalism.35 For instance, although it is not endorsed by the overwhelming majority of Chinese physicians today, principles such as the primacy of patients’ welfare are clearly enunciated in traditional Chinese medical ethics, most notably in the Lun Dayi Jingcheng (On the Excellence and Sincerity of the Master Physician) of

Articles from The Journal of Clinical Ethics are copyrighted, and may not be reproduced, sold, or exploited for any commercial purpose without the express written consent of The Journal of Clinical Ethics. Volume 26, Number 1 Sun Simiao (circa CE 581-682).36 Written in the early Tang Dynasty, Lun Dayi Jingcheng is probably the most influential concise formulation of medical ethics to have emerged in China, enjoying a status comparable to the Hippocratic oath in the West. In it, Sun lays out the moral characteristics of what he called the Master Physician: “When the ill come for help, whether they are noble or lowly, rich or poor, old or young, handsome or homely, enemies or good friends, Chinese or foreigners, intelligent or simpleminded, the Master Physician should pay no attention to any of these things but rather should treat all his patients equally, as if they were his closest relatives.”37 A good physician must first cultivate a heart of genuine and deep compassion for human pain, suffering, and distress: “When a Master Physician practices medicine, he must calm his mind . . . develop a heart of great mercy and compassion, and solemnly pledge to relieve without any discrimination the pains from which the souls of all existences [hanling]—human beings—suffer.38 Most importantly, a Master Physician should always show selfless commitment to patients: A physician should not be overcautious and indecisive, should not worry about good or bad luck, and should not be concerned about his own body and life. Seeing the patient unwell, a physician should feel as if he himself had been struck down. With deep sympathy welling up from the bottom of his heart, a physician should not merely appear to have done his best, but get involved wholeheartedly—not worrying whether the location is dangerous and precipitous, the time is day or night, the weather cold or hot, or whether he himself is hungry, thirsty and exhausted. Whoever practices medicine in this way is a Master Physician to all human beings. Whoever practices medicine in a contrary way is the worst enemy of humankind.39 These passages can be read as embodying the ancient Chinese expressions of the modern principles of the primacy of patients’ welfare. Sun’s ethics was heavily influenced by the three major sociocultural, moral, and religious traditions of China— Confucianism, Daoism, and Buddhism—and is endorsed as well by Chinese socialist medical ethics whose slogan, “Serve patients wholeheartedly,” supports the basic tenets of the Charter. Furthermore, we may also cite the principle of yi nai renshu (medicine as the art of humanity), a Confucian tenet based on the moral, political, and spiritual concept of ren, variously translated in English as “benevolence,” “perfect virtue,” “love,” “al-


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truism,” and “humanity.” Consistent with the global claim of the Charter, this ancient principle defines healing as a moral and humanistic enterprise that is universal in its calling. Given the broad social, economic, and political forces confronting medicine today, including the commodification of healthcare and the demands of the state, the ancient Chinese concept of yi nai renshu is especially relevant to a the profession in order to uphold medicine as “the art of humanity.”40 An adequate discussion of the significance of traditional Chinese medical ethics for today’s medical professionalism in China—and globally—needs much greater in-depth study. Because the purpose of this article is to offer a transcultural interpretation of the similarities and differences of the results of two national surveys from China and the U.S., we limit our discussion of this important subject to the fragmented citations and very brief commentary presented above. Our point is that, besides acknowledging possible common grounds in medical professionalism across cultures and societies, a transcultural approach advocates for the great historical richness and contemporary potentials of indigenous medical ethics traditions in Chinese and other nonWestern cultures, which should not be oversimplified as merely the “radical other” of the West. In this regard, a critique of the Charter may be made. As it stands, in spite of its global ambition and emphasis on the universality of core principles and commitments of medical professionalism, the Charter has far from sufficiently acknowledged—in fact not acknowledged at all—the positive elements of medical ethics traditions of non-Western cultures, Chinese cultures included. Reviving the traditional Chinese values of professional ethics of medicine not only helps address practical challenges of medical professionalism in China today, such as the issues of social justice and patient-physician trust, but revising indigenous Chinese medical ethics traditions, such as the notion of “medicine as the art of humanities,” can contribute to global discourse on medical professionalism through, for example, offering alternative conceptual frameworks on the moral ends of healing and medicine as a profession. Specific research into these matters is needed. THE CHINA-U.S. DIALOGUE The word “Chimerica” was coined to describe the integration of U.S. and Chinese markets and financial arrangements.41 A less remarked upon convergence is the sociopolitical circumstances of the two nations, as China continues to transform from a



socialist to a capitalist nation, and the U.S.—in the wake of the near-collapse of Western financial institutions in the past decade—may be moving toward a more socialist regard for the collective good. These possibly converging trends make the emergence of a unified medical profession all the more necessary, and we are pleased to note the important efforts undertaken by physicians to promote a global discourse on the core commitments of medical professionalism. For example, in 2008, the China-U.S. Center on Medical Professionalism was established at the Peking University Health Science Center in collaboration with the Columbia University Center on Medicine as a Profession, with a mandate to promote and support research and educational activities in the field of medical professionalism in China. Since it opened, the center has organized a series of international conferences and sponsored a number of Chinese research projects, including a national survey of Chinese patients regarding the notorious practice of “red envelopes” (“gifts” of cash traditionally contained in a red envelope42) and the national survey of Chinese physicians on attitudes to medical professionalism that has been discussed in this article. The Chinese Medical Doctors Association has joined other respected medical institutions in publicizing and promoting the Charter, and has strongly endorsed measures to familiarize medical students with its principles. In the U.S., efforts are already underway to make the Charter and its principles familiar to physicians in training, notably in courses and electives developed around community service learning, which not only integrate the principles of professionalism into the medical curriculum, but aim to put those principles into practice.43 Chinese medical educators are exploring similar means using sessions devoted to social justice and other related topics, appearing, for example, at the national conference on Medical Humanities held annually at the College of Medical Humanities at the Peking University Medical School. The transcultural approach advocated here upholds not only the necessity but also the feasibility of genuine and productive cross-cultural dialogue in every sphere of social life, including healthcare. Once-popular notions of the incommensurability of East and West limited the possibility of such an important dialogue and fostered the self-defeating belief that the clash of civilizations and cultures is inevitable. This may prove to be the case vis-a-vis certain economic and geopolitical ambitions, but, with respect to medical professionalism, our experience and the intellectual explorations involved in pro-

Spring 2015 ducing this article have led us to a different conclusion. CONCLUSIONS In general, we find that the fundamental principles and core commitments of the Charter are endorsed by U.S. and Chinese physicians alike, and that, contrary to stereotypes, Chinese culture and traditional medical ethics are supportive of the moral commitments demanded by modern medical professionalism, at least in spirit. In order to better understand the complexity of cross-cultural differences and transcultural commonalities, we have offered a transcultural interpretation of medical professionalism in China in comparison with the U.S. Above all, we have asserted the necessity and feasibility of genuine cross-cultural dialogue in the area of medical professionalism: American or Chinese, physicians face similar challenges as they seek a principled balance between what is best for the patient, what is just for society, and what is proper for themselves. ACKNOWLEDGMENTS Thanks go to Paul Sorrell, PhD, for his professional editing and to Albany Lucas for her research assistance. This article has been significantly revised as a response to the extensive comments from two anonymous reviewers. Thanks for their helpful input. NOTES 1. Medical Professionalism Project of the ABIM Foundation, ACP-ASIM Foundation, and Europe Federation of Internal Medicine, “Medical Professionalism in the New Millennium: A Physician Charter,” Annals of Internal Medicine 136, no. 3 (February 2002): 243-6, http:// www.abimfoundation.org/~/media/Foundation/Professionalism/Physician%20Charter.ashx?la=en, accessed 11 December 2014. 2. Ibid. 3. W. Hsiao and L. Hu, “The State of Medical Professionalism in China—Past, Present, Future,” in Prospects for the Professions in China, ed. W.P. Alford, K. Winston, and W.C. Kirby (London: Routledge, 2011): 111-28. 4. L. Hu, X. Yin, X. Bao, and J.-B. Nie, “Chinese Physicians’ Attitudes Toward and Understanding of Medical Professionalism: Results of a National Survey,” The Journal of Clinical Ethics 25, no. 2 (Summer 2014): 135-47. 5. E.G. Campbell et al., “Professionalism in Medicine: Results of a National Survey of Physicians,” Annals of Internal Medicine 147, no. 11 (December 2007): 795-802. 6. E.W. Said, Orientalism (New York: Vintage, 1979). 7. J.B. Nie, Medical Ethics in China: A Transcultural Interpretation (London and New York: Routledge, 2011),

Articles from The Journal of Clinical Ethics are copyrighted, and may not be reproduced, sold, or exploited for any commercial purpose without the express written consent of The Journal of Clinical Ethics. Volume 26, Number 1 chap. 1. 8. R.C. Fox and J.P. Swazey, “Medical Morality Is Not Bioethics: Medical ethics in China and the United States,” Perspectives in Biology and Medicine 27 (1984): 336-60. 9. J.-B. Nie, “The Specious Idea of an Asian Bioethics: Beyond Dichotomizing East and West,” in Principles of Heath Care Ethics, 2nd ed., ed. R.E. Ashcroft, A. Dawson, H. Draper, and J.R. McMillan (London: John Wiley & Sons, 2007): 143-9; J.-B. Nie, “The Fallacy and Danger of Dichotomizing Cultures: The Truth about Medical TruthTelling in China,” Virtual Mentor 14, no. 4 (April 2012): 338-43, http://virtualmentor.ama-assn.org/2012/04/ msoc1-1204.html, accessed 11 December 2014. 10. Nie, Medical Ethics in China, see note 7 above. 11. C.Y. Ding, “Family members’ informed consent to medical treatment for competent patients in China,” China: An International Journal 8, no. 1 (2010) :139-50. 12. Y. Cong, “Doctor-Family-Patient Relationship: The Chinese Paradigm of Informed Consent,” Journal of Medicine and Philosophy 29, no. 2 (2004): 149-178. 13. I. Kant, Groundwork of the Metaphysic of Morals, trans. H. J. Paton (New York: Harper & Row, 1964), see especially pp. 98-9 of the text and Professor Paton’s “Analysis of the Argument,” pp. 41-2. 14. National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, “The Belmont Report,” 1979, http://www.hhs.gov/ohrp/ humansubjects/guidance/belmont.html, accessed 11 December 2014. 15. H.L. Nelson and J.L. Nelson, The Patient in the Family: An Ethics of Medicine and Families (New York: Routledge, 1995). 16. H. Roetz, Confucian Ethics of the Axial Age (Albany, N.Y.: State University of New York Press, 1993). 17. Ibid; see also O. Döring, Chinas Bioethik verstehen (Hamburg, Germany: Abera Verlag, 2004); O. Döring, “Cheng als das stimmige Ganze der Integrität: Ein Interpretationsvorschlag zur Ethik,” in Auf Augenhöhe Festschrift von Heiner Roetz, Bochum University Yearbook for East-Asian Studies, vol. 38, ed. W. Behr, L.C. Giacinto, O. Döring, and C. Moll-Murata (Munich, Germany: IUDICIUM Verlag GmbH, 2015), 39-62; J-B. Nie, “Confucian Universalism for Human Rights and Global Bioethics, in Auf Augenhöhe Festschrift von Heiner Roetz, ibid., 115-28. 18. Ding, “Family members’ informed consent to medical treatment,” see note 11 above. 19. E. Hui, “Parental refusal of life-saving treatments for adolescents: Chinese familism in medical decisionmaking re-visited,” Bioethics 22, no. 2 (2008): 286-95. 20. F. Engels, Origin of the Family, Private Property and the State (Atlanta, Ga.: Pathfinder, 1972). 21. C. Garcia-Moreno et al., “Prevalence of intimate partner violence: Findings from the WHO multi-country study on women’s health and domestic violence,”Lancet 368 (7 October 2006): 1260-9; W.L. Parish et al., “Intimate Partner Violence in China: National Prevalence, Risk Factors and Associated Health Problems,” International Family Planning Perspectives 34, no. 4 (2004):174-81. 22. J.B. Nie, “China’s One-Child Policy, a Policy with-


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out a Future: Pitfalls of the Common Good Argument and the Authoritarian Model,” Cambridge Quarterly of Healthcare Ethics 23, no. 2 (2014): 272-87. 23. Cong, “Doctor-Family-Patient Relationship,” see note 12 above, p. 154. 24. For a systematic and detailed exploration of these issues, see Nie, Medical Ethics in China, note 7 above, chaps. 6 and 7; and see Nie, “The Fallacy and Danger of Dichotomizing Cultures, note 9 above. 25. American Medical Association, Code Of Ethics Of The American Medical Association Adopted May, 1847 (Charleston, S.C.: Nabu Press, 2011, orginally published by Wm. F. Fell, 1871), http://www.ama-assn.org/ama/pub/ about-ama/our-history/history-ama-ethics.page?, accessed 11 December 2014. 26. Nie, Medical Ethics in China, see note 7 above, chaps. 6 and 7; and see Nie, “The Fallacy and Danger of Dichotomizing Cultures, note 9 above. 27. Ibid. 28. J. Tang, “The elephant in the operating room: A qualitative study on disclosing senior physicians’ errors,” paper presented at the 12th World Congress of Bioethics, 25-27 June 2014, Mexico City. 29. American Board of Internal Medicine, “Project Professionalism,” 1995, p. 1, http://www.abimfoundation. org/ ~/media/Foundation/Professionalism/Project% 20professionalism.ashx?la=en, accessed 11 December 2014. 30. J.B. Imber, Trusting Doctors: The Decline of Moral Authority in American Medicine (Princeton, N.J.: Princeton University Press, 2008). 31. Cited and discussed in X. Zhang and M. SleeboomFaulkner, “Tension between Medical Professionals and Patients in Mainland China,” Cambridge Quarterly of Healthcare Ethics 20 (2011): 458-65. 32. Ibid. 33. “Chinese doctors are under threat,” Editorial, Lancet 376, no. 9742 (28 August 2010): 657, http://www. thelancet.com/journals/lancet/article/PIIS01406736(10)61315-3/fulltext, accessed 11 December 2014; S. LaFraniere, “Chinese Hospitals Are Battlegrounds of Discontent,” New York Times, 11 August 2010. 34. J. Tucker et al., “Reviving medicine as the art of humanity in China,” Letter, Lancet 383, no. 9927 (26 April 2014): 1462-63. 35. J.B. Nie, “The Discourses of Practitioners in China,” in The Cambridge World History of Medical Ethics, ed. R. Baker and L. McCullough (New York and London: Cambridge University Press, 2008), chap. 21, 33544. 36. M. Chen, ed., Gujin Tushu Jicheng Yibu Quanlu (Collection of Ancient and Modern Books, The Part of Medicine), Book 12: General Discussions (Beijing: People’s Health Press, 1991, first published in 1723, volumes 501520 in the original), 18-9. A complete English translation is available in P.U. Unschuld, Medical Ethics in Imperial China (Berkeley and London: University of California Press, 1979), 29-33. 37. Cited and discussed in Nie, Medical Ethics in China, see note 7 above, chap. 11. Emphasis added.



38. Ibid. 39. Ibid. Emphasis added. 40. Nie, Medical Ethics in China, see note 7 above, chap. 12. 41. N. Ferguson and M. Schularick, “The End of Chimerica,” International Finance 14, no. 1 (2011): 1-26. 42. X. Kong et al., “Red Envelope and Doctor-Patient Trust—Report 7 of a National Survey of 4000 Patients in 10 Cities,” Medicine and Philosophy 32, no. 5 (2011): 347, 48. 43. K. Smith et al., “Integrating community service learning into the medical school curriculum,” Medical Teacher 35, no. 5 (2013): e1139-e1148, doi:10.3109/ 0142159X.2012.735383; D. Muller et al., “The Role of Social and Community Service in Medical Education: The Next 100 Years,” Academic Medicine 85, no. 2 (2010): 3029; K. Smith, R. Saavedra, J. Raeke, and A. O’Donell, “The journey to creating a campus-wide culture of professionalism,” Academic Medicine 82, no. 11 (2007): 1015-21.

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