Background Based on the principle of informed consent, doctors are required to fully inform patients and respect their medical decisions. In China, however, family members usually play a special role in the patient’s informed consent, which creates a unique “doctor-family-patient” model of the physician-patient relationship. Our study targets young doctors to investigate the ethical dilemmas they may encounter in such a model, as well as their attitudes to the family roles in informed consent. Methods A questionnaire was developed including general (...) demographic characteristics, the fulfillment of the obligation to fully inform, who will be informed, and the ethical dilemmas in decision-making. We recruited a total of 421 doctors to complete this questionnaire, of which 368 met the age requirements for this study. Cross tabulation and Pearson’s chi-squared test were used to analyze the differences between types of patients for categorical variables, and a p-value < 0.05 was considered statistically significant. Results Our data shows that only 20 doctors (5.40%) stated “informing the patient alone is sufficient” when it comes to informing patients of their serious conditions. The rest of the participants would ensure that the family was informed. When facing elderly patients with decision-making capacity, the data was statistically different (3.8%; P < 0.001) The primary reason for ensuring that family members be informed differs among the participants. In addition, when family members asked doctors to conceal the patient’s medical condition for the best interests of patients, 270 doctors (73.4%) would agree and cooperate with the family. A similar proportion (79.6%) would do so when it comes to elderly patients. Conclusions (1) Chinese doctors pay extra attention to informing the patient’s family, which may not be in the patient’s best interests. (2) Chinese doctors treat adult (but not elderly) patients and elderly patients differently when it comes to informing family members. (3) When family members request that doctors withhold information from patients “in the best interest of the patient,” the majority choose to comply with the request, although this may cause them distress. (shrink)

Medical research must involve the participation of human subjects. Knowledge of patients' perspectives and concerns with their involvement in research would enhance recruitment efforts, improve the informed consent process, and enhance the overall trust between patients and investigators. Several studies have examined the views of patients from Western countries. There is limited empirical research involving the perspectives of individuals from developing countries. The purpose of this study is to examine the attitudes of Egyptian individuals toward medical research. Such information would (...) help clarify the type and extent of concerns regarding research participation of individuals from cultural, economic, and political backgrounds that differ from those in developed countries. (shrink)

Healthcare systems in Singapore, Hong Kong, and mainland China are strikingly distinct from those in the West. Economically speaking, each of the aforementioned Eastern systems relies in great measure on private expenditures supplemented by savings accounts. Western nations, on the other hand, typically exhibit government funding and wariness about healthcare savings accounts. This essay argues that these and other differences between Pacific Rim healthcare systems and Western systems should be assessed in light of background Confucian commitments operating in the former. (...) In the Confucian context, bioethics and healthcare policy have a unique content, texture, and set of implications that often affront Western assumptions about the appropriate individual autonomy of patients and the appropriate character of social safety nets for healthcare. (shrink)

Although Chinese law imposes informed consent for medical treatments, the Chinese understanding of this requirement is very different from the European one, mostly due to the influence of Confucianism. Chinese doctors and relatives are primarily interested in protecting the patient, even from the truth; thus, patients are commonly uninformed of their medical conditions, often at the family’s request. The family plays an important role in health care decisions, even substituting their decisions for the patient’s. Accordingly, instead of personal informed consent, (...) what actually exists is ‘family informed consent’. From a Western perspective, these features of Chinese law and Chinese culture might seem strange, contradicting our understanding of doctor-patient relationship and even the very essence of self-determination and fundamental rights. However, we cannot forget the huge influence of cultural factors in these domains, and that ‘Western’ informed consent is grounded on the individualistic nature of Western culture. This article will underline the differences between the Western and the Chinese perspectives, clarifying how each of them must be understood in its own cultural environment. But, while still respecting Chinese particularities, this paper advocates that China adopt patient individual informed consent because this is the only solution compatible with human dignity and human rights. (shrink)

Informed consent honors the autonomous decisions of patients, and family consent places importance on decisions made by their families. However, there is little understanding of the relationship between these two medical decision-making approaches. Both approaches exist in Japan as part of its truth disclosure policy. What is the status of family consent in the United States, from which Japan introduced informed consent? This paper compares the situation in the United States with that in Japan, where family consent has been combined (...) with informed consent. It then explains the history of policy development through which family consent was added to informed consent in the United States. Based on this analysis, the paper suggests that the relationship between informed consent and family consent in the United States was established on the basis of a family model that places more importance on trust-based relationships than it does on blood ties. (shrink)

The social interface between reproductive medicine and embryonic stem cell research has been investigated in a pilot study at a large IVF clinic in central China. Methods included observation, interviews with hospital personnel, and five in-depth qualitative interviews with women who underwent IVF and who were asked for their consent to the donation of embryos for use in medical (in fact human embryonic stem cell) research. This paper reports, and discusses from an ethical perspective, the results of an analysis of (...) these interviews. The participants talked of extreme social pressure to become pregnant. Once they had a baby, ‘spare’ embryos lost practical significance due to the Chinese one-child policy. In the context of decision making about donating embryos to research, the women used the clinical distinctions between ‘good and bad quality’ embryos and also between frozen and transferred embryos, as guiding moral distinctions. In the absence of concrete information about what sort of research their embryos should be used for, the women interviewed either refused consent (for fear that the embryo would be given to another couple) or accepted, expressing motives of solidarity with other women in a similar situation. This reveals that they filled the knowledge gap with an image of research improving fertility treatment. (shrink)

The practice of medicine—and especially the patient-doctor relationship—has seen exceptional shifts in ethical standards of care over the past few years, which by and large originate in occidental countries and are then extrapolated worldwide. However, this phenomenon is blind to the fact that an ethical practice of medicine remains hugely dependent on prevailing cultural and societal expectations of the community in which it serves. One model aiming to conceptualise the dichotomous efforts for global standardisation of medical care against differing sociocultural (...) expectations is the individualism-collectivism model, with the ‘West’ being seen as individualistic and the ‘East’ being seen as collectivistic. This has been used by many academics to explain differences in approach towards ethical practice on key concepts such as informed consent and patient autonomy. However, I argue that this characterisation is incomplete and lacks nuance into the complexities surrounding cross-cultural ethics in practice, and I propose an alternative model based on the ethics of clinical care in Hong Kong, China. Core ethical principles need not be culture-bound—indeed, their very existence mandates for them to be universal and non-derogable—but instead cultural alignment occurs in the particular implementation of these principles, insofar as they respect the general spirit of contemporary ethical standards. (shrink)

Familialism is a significant mindset within Singaporean culture. Its effects through the practice of familial determination and filial piety, which calls for a family centric approach to care determination over and above individual autonomy, affect many elements of local care provision. However, given the complex psychosocial, political and cultural elements involved, the applicability and viability of this model as well as that of a physician-led practice is increasingly open to conjecture. This article will investigate some of these concerns before proffering (...) a decision-making process based upon a multidisciplinary team approach. It will be shown that such a multidimensional and multiprofessional approach is more in keeping with the inclusive and patient-centred ethos of palliative care than prevailing practices. It will be shown that such an approach will also be better placed to deliver holistic, coherent and sensitive end-of-life care that palliative care espouses. (shrink)

Decisions regarding clinical procedures or research participation typically require the informed consent of individuals. When individuals are unable to give consent, the informed permission of a legally authorized representative or surrogate is required. Although many proposed procedures are aimed primarily at benefiting the individual, some are not. I argue that, particularly when individuals are asked to assume risks primarily or exclusively for the benefit of others, family members ought to be engaged in the informed consent process. Examples of procedures in (...) which individuals are asked to assume risks primarily or exclusively for the benefit of others include living organ donation and research participation. (shrink)

In most, if not all, jurisdictions with active organ transplantation programs, there is a persistent desire to increase donation rates because the demand for transplantable organs exceeds the supply. China, in particular, faces an extraordinary gap between the number of organs donated by deceased donors and the number of people seeking one or more transplants. China might look to Western countries with higher donation rates to determine how best to introduce Western practices into the Chinese system. In attempting to increase (...) its organ donation rate, China must not only ensure that its organ donation system reflects different Chinese cultural values, but also that it avoids the ethical problems of the United States and of other Western systems. This article examines four such problems. They concern the family, obtaining permission for organ donation, the definition and diagnosis of “brain death,” and trust. Revisions to the Chinese system should involve a careful look to China and Chinese cultural resources rather than to Western models. (shrink)

This paper reports two cases in Hong Kong involving two native Chinese adolescent cancer patients (APs) who were denied their rights to consent to necessary treatments refused by their parents, resulting in serious harm. We argue that the dynamics of the ‘AP‐physician‐family‐relationship’ and the dominant role Chinese families play in medical decision‐making (MDM) are best understood in terms of the tendency to hierarchy and parental authoritarianism in traditional Confucianism. This ethic has been confirmed and endorsed by various Chinese writers from (...) Mainland China and Hong Kong. Rather than giving an unqualified endorsement to this ethic, based more on cultural sentimentalism than rational moral reasoning, we warn that a strong familism in MDM, which deprives ‘weak’ family members of rights, represents the less desirable elements of this tradition, against which healthcare professionals working in this cultural milieu need to safeguard. Specifically for APs, we suggest that parental authority and family integrity should be re‐interpreted in terms of parental responsibility and the enhancement of children's interests respectively, as done in the West. This implies that when parents refuse to consent to necessary treatment and deny their adolescent children's right to consent, doctors, as the only remaining advocates of the APs' interest, have the duty to inform the state, which can override parental refusal to enable the doctors to fulfill their professional and moral obligations. In so doing the state exercises its ‘parens patriae’ power to defend the defenseless in society and the integrity of the medical profession. (shrink)

Background: Dignified care is one of the main objectives of holistic care. Furthermore, paying attention to dignity as one of the fundamental rights of patients is extremely important. However, in many cases, the dignity of hospitalized patients is not considered. Dignity is an abstract concept, and comprehensive studies of the dignity of Iranian patients hospitalized in general hospital settings are limited. Objective: The aim of this study was to explore the concept of dignity from the perspective of patients hospitalized in (...) general hospital settings in Iran. Research design: This study takes a qualitative approach. Data were gathered using individual, semi-structured interviews. Qualitative content analysis was the method used to analyse and interpret the data. The criteria suggested by Guba and Lincoln were used ensure the trustworthiness of the study. Participants and research context: A total of 14 hospitalized patients in general hospital settings in Shiraz participated in this study. Ethical considerations: The Research Ethics Committee of the Shiraz University of Medical Sciences approved the protocol of the study and the ethical principles were followed throughout. Findings: The findings of this study revealed four main themes – ‘respectful atmosphere’, ‘patient privacy’, ‘preservation of authority’ and ‘receiving attention’ – and 10 categories. Discussion: Patients need to be hospitalized in a respectable environment in which their privacy is preserved and paid attention, providing them with sufficient authority in terms of medical decisions and their life-related issues. The dignity of hospitalized patients will be preserved under these conditions. Conclusion: Patients hospitalized in general hospital settings need to retain their dignity. This can contribute to the optimal therapeutic outcomes for them. Therefore, it is suggested that a cultural, professional and institutional background, in which all components of the patient’s dignity are protected and emphasized, should be provided. (shrink)

This essay argues that the Chinese Mental Health Act of 2013 is overly individualistic and fails to give proper moral weight to the role of Chinese families in directing the process of decision-making for hospitalizing and treating the mentally ill patients. We present three types of reactions within the medical community to the Act, each illustrated with a case and discussion. In the first two types of cases, we argue that these reactions are problematic either because they comply with the (...) law but undermine the patient’s interests by refusing the family’s request to have the patient hospitalized, or violate the law by hospitalizing patients in response to the real concerns of their families. In the third type of situation, psychiatrists inappropriately encourage families to produce evidence of the patient’s behavior that is harmful to self or others in order legally to commit the patient. Each of these problems, we conclude, should be tackled by supplementing Article 30 of the Act with the stipulation that a psychiatrist may authorize the involuntary hospitalization of a patient, who is not at risk of causing physical harm to self or others, with the consent of all major family members. Drawing on the deeply culturally embedded moral traditions of Confucian medical familism, this proposal would facilitate the proper treatment of a significant number of Chinese mentally ill patients under the care of their families. (shrink)

The family is the exemplar community of Chinese society. This essay explores how Chinese communitarian norms, expressed in thick commitments to the authority and autonomy of the family, are central to contemporary Chinese bioethics. In particular, it focuses on the issue of surrogate decision making to illustrate the Confucian family-grounded communitarian bioethics. The essay first describes the way in which the family, in Chinese bioethics, functions as a whole to provide consent for significant medical and surgical interventions when a patient (...) has lost decision-making capacity. It is argued that the practice of not having an established order for surrogate decision makers (e.g., spouse, children, and then parents), as it is done in the United States, reflects the acknowledgment that the family as a social reality cannot be reduced to a stereotype of the appropriate order of default decision makers. This description of the family as being in authority to make surrogate decisions for an incompetent family member is enriched by an elaboration of the differences among the concepts of patient autonomy, family autonomy, and moral autonomy. The Chinese model, as well as the Confucian communitarian life of families, engages a family autonomy that is supported by a Confucian understanding of moral autonomy, rather than individual autonomy. Finally, the issue of possible conflicts between patient and family interests in relation to a patient’s past wishes in the Chinese model is addressed in light of the role of the physician. (shrink)

Most writing on informed consent in Africa highlights different cultural and social attributes that influence informed consent practices, especially in research settings. This review presents a composite picture of informed consent in Nigeria using empirical studies and legal and regulatory prescriptions, as well as clinical experience. It shows that Nigeria, like most other nations in Africa, is a mixture of sociocultural entities, and, notwithstanding the multitude of factors affecting it, informed consent is evolving along a purely Western model. Empirical studies (...) show that 70–95% of Nigerian patients report giving consent for their surgical treatments. Regulatory prescriptions and adjudicated cases in Nigeria follow the Western model of informed consent. However, adversarial legal proceedings, for a multiplicity of reasons, do not play significant roles in enforcing good medical practice in Nigeria. Gender prejudices are evident, but not a norm. Individual autonomy is recognized even when decisions are made within the family. Consent practices are influenced by the level of education, extended family system, urbanization, religious practices, and health care financing options available. All limitations notwithstanding, consent discussions improved with increasing level of education of the patients, suggesting that improved physician's knowledge and increasing awareness and education of patients can override other influences. Nigerian medical schools should restructure their teaching of medical ethics to improve the knowledge and practices of physicians. More research is needed on the preferences of the Nigerian people regarding informed consent so as to adequately train physicians and positively influence physicians' behaviors. (shrink)

Once God is no longer recognized as the ground and the enforcer of morality, the character and force of morality undergoes a significant change, a point made by G.E.M. Anscombe in her observation that without God the significance of morality is changed, as the word criminal would be changed if there were no criminal law and criminal courts. There is no longer in principle a God's-eye perspective from which one can envisage setting moral pluralism aside. In addition, it becomes impossible (...) to show that morality should always trump concerns of prudence, concerns for one's own non-moral interests and the interests of those to whom one is close. Immanuel Kant's attempt to maintain the unity of morality and the force of moral obligation by invoking the idea of God and the postulates of pure practical reason are explored and assessed. Hegel's reconstruction of the status of moral obligation is also examined, given his attempt to eschew Kant's thing-in-itself, as well as Kant's at least possible transcendent God. Severed from any metaphysical anchor, morality gains a contingent content from socio-historical context and its enforcement from the state. Hegel's disengagement from a transcendent God marks a watershed in the place of God in philosophical reflections regarding the status of moral obligations on the European continent. Anscombe is vindicated. Absent the presence of God, there is an important change in the force of moral obligation. (shrink)

Once God is no longer recognized as the ground and the enforcer of morality, the character and force of morality undergoes a significant change, a point made by G.E.M. Anscombe in her observation that without God the significance of morality is changed, as the word criminal would be changed if there were no criminal law and criminal courts. There is no longer in principle a God's-eye perspective from which one can envisage setting moral pluralism aside. In addition, it becomes impossible (...) to show that morality should always trump concerns of prudence, concerns for one's own non-moral interests and the interests of those to whom one is close. Immanuel Kant's attempt to maintain the unity of morality and the force of moral obligation by invoking the idea of God and the postulates of pure practical reason are explored and assessed. Hegel's reconstruction of the status of moral obligation is also examined, given his attempt to eschew Kant's thing-in-itself, as well as Kant's at least possible transcendent God. Severed from any metaphysical anchor, morality gains a contingent content from socio-historical context and its enforcement from the state. Hegel's disengagement from a transcendent God marks a watershed in the place of God in philosophical reflections regarding the status of moral obligations on the European continent. Anscombe is vindicated. Absent the presence of God, there is an important change in the force of moral obligation. (shrink)

This paper presents four different understandings of the family and their concomitant views of the authority of the family in pediatric medical decision making. These different views are grounded in robustly developed, and conflicting, worldviews supported by disparate basic premises about the nature of morality. The traditional worldviews are often found within religious communities that embrace foundational metaphysical premises at odds with the commitments of the liberal account of the family dominant in the secular culture of the West. These disputes (...) are substantial and ultimately irresolvable by sound rational argument because of the failure to share common foundational premises and rules of evidence. It is in light of these fundamental disagreements that there is a need to evaluate critically the claims and agenda advanced by the Convention on the Rights of the Child. (shrink)

Most writing on informed consent in Africa highlights different cultural and social attributes that influence informed consent practices, especially in research settings. This review presents a composite picture of informed consent in Nigeria using empirical studies and legal and regulatory prescriptions, as well as clinical experience. It shows that Nigeria, like most other nations in Africa, is a mixture of sociocultural entities, and, notwithstanding the multitude of factors affecting it, informed consent is evolving along a purely Western model.Empirical studies show (...) that 70–95% of Nigerian patients report giving consent for their surgical treatments. Regulatory prescriptions and adjudicated cases in Nigeria follow the Western model of informed consent. However, adversarial legal proceedings, for a multiplicity of reasons, do not play significant roles in enforcing good medical practice in Nigeria. Gender prejudices are evident, but not a norm. Individual autonomy is recognized even when decisions are made within the family. Consent practices are influenced by the level of education, extended family system, urbanization, religious practices, and health care financing options available. All limitations notwithstanding, consent discussions improved with increasing level of education of the patients, suggesting that improved physician's knowledge and increasing awareness and education of patients can override other influences.Nigerian medical schools should restructure their teaching of medical ethics to improve the knowledge and practices of physicians. More research is needed on the preferences of the Nigerian people regarding informed consent so as to adequately train physicians and positively influence physicians’ behaviors. (shrink)

The main objective of the study was to survey health-care practitioners' (HCPs) perception of health-care practices that are of medical–ethical importance in Hong Kong public hospitals, and to identify the moral issues that concern them most. A total of 2718 doctors, nurses, allied health and administrative workers from 14 hospitals participated. HCPs considered that communication/conflict between patients/families and HCPs was the most important issue, followed by issues concerning patients' rights and values. The ‘ethics climate’ in Hong Kong public hospitals was (...) found to be largely determined by two negative factors (inadequate communication and conflict issues) and two positive factors (high regard for patients' rights and the decline in family interference). Chinese cultural conventions were inferred to exert strong influence on the behaviours of HCPs and patients/families. Significant differences in perceptions between different categories of HCPs were also detected. The study was the first of its kind ever done in Hong Kong and signalled the need for institutional reorganization and medical–ethical education. (shrink)

This essay illustrates what the Chinese family-based and harmony-oriented model of medical decision making is like as well as how it differs from the modern Western individual-based and autonomy-oriented model in health care practice. The essay discloses the roots of the Chinese model in the Confucian account of the family and the Confucian view of harmony. By responding to a series of questions posed to the Chinese model by modern Western scholars in terms of the basic individualist concerns and values (...) embedded in the modern Western model, we conclude that the Chinese people have justifiable reasons to continue to apply the Chinese model to their contemporary health care and medical practice. (shrink)

This paper challenges the foundational claim that the human family is no more than a social construction. It advances the position that the family is a central category of experience, being, and knowledge. Throughout, the analysis argues for the centrality of the family for human flourishing and, consequently, for the importance of sustaining family-oriented practices within social policy, such as more family-oriented approaches to consent to medical treatment. Where individually oriented approaches to medical decision-making accent an ethos of isolated personal (...) autonomy family-oriented approaches acknowledge the central social and moral reality of the family. I argue that the family ought to be appreciated as more than a mere network of personal relations and individual undertakings; the family possesses a being that is social and moral such that it realizes a particular structure of human good and sustains the necessary conditions for core areas of human flourishing. Moreover, since the family exists as a nexus of face-to-face relationships, the consent of persons, including adults, to be members of a particular family, subject to its own respective account of family sovereignty, is significantly more amply demonstrated than the consent of citizens to be under the authority of a particular state. As a result, in the face of a general Western bioethical affirmation of the autonomy of individuals, as if adults and children were morally and socially isolated agents, this paper argues that social space must nevertheless be made for families to choose on behalf of their own members. (shrink)

Despite the well-documented social, economic, and adaptive advantages for young children, adolescents, and adults, the traditional family in the West is in decline. A growing percentage of men and women choose not to be bound by the traditional moral and social expectations of marriage and family life. Adults are much more likely than in the past to live as sexually active singles, with a concomitant increase in forms of social isolation as well as in the number of children born outside (...) of marriage. These social shifts are also connected to public policies that provide incentives for individuals to exit the family, leaving behind its social, capital, and economic resources. The individualistic character of the social-democratic egalitarian ideology that underlies the current dominant approaches to health care financing in Western Europe and much of North America, for example, is associated with a decline in family stability. Welfare entitlements, including state-based health care, have made it easier to exit the family, undermining the centrality of the family’s core human relationships. This essay argues for the importance of recognizing the cardinal role and reality of the family and for the importance of family-based health care savings accounts for preserving family integrity, while also providing for sustainable long-term health care reform. (shrink)

This paper explores organ donation through the perspective of Reconstructionist Confucianism. I argue that for organ donation in China to be morally permissible, public policy must conform to the norms of Confucian benevolence. Reconstructionist Confucianism appreciates benevolence as an objectively important feature of morality deeply connected to moral rules governing propriety, integrity, righteousness, and human freedom. Here, benevolence involves sincere affection for another as an intrinsic good, rather than as a means to achieve other purposes. It requires developing self-restraint and (...) proper respect for others. As I argue, family-based consent is essential for ensuring that organ donation conforms to such an understanding of benevolence and is, thereby, compatible with Confucian culture. Consequently, legislation in China should solidify family-based consent for organ donation to consolidate a benevolent family environment as the basis of morality, law, and social existence. (shrink)

This study is a contribution to Chinese-Western dialogue of bioethics but perhaps the first one of its kind. From a Chinese-Western comparative ethical perspective, this work brings Chinese ethical theories, especially Confucian ethics, into a contemporary context of the epidemic of HIV/AIDS, and to see how the deeply-rooted thoughts of Confucius interact, compete, or integrate with concepts from Western ethical traditions. An underlying belief is that some ideas in Confucian ethics are important and insightful beyond their cultural and historical origins (...) in China and other Confucianism influenced societies.Methodologically, this thesis employs two approaches, conceptual normative analysis combined with critical interpretation. The ‘interpretive’ approach I employ, as an important methodology supplementing my normative analysis, not only deals with Chinese ancient texts, but also explains specific beliefs and practices in China.With a critical eye, this thesis carefully examines a number of key topics in the ethics of AIDS in China from a cross-cultural perspective. Topics including: views on personhood and the vulnerability of People Living with HIV/AIDS; prioritising and balancing the role of ‘harm reduction’ and the role of ‘eradication of deviant behaviour’ in AIDS policy in China; rights-based opt-out approach and duty-based family-centred approach in HIV testing and Biobanking; blood donation; moral responsibility and personal responsibility for health; and the popular rhetoric of ‘innocent infection’ versus ‘guilty infection’ in AIDS. My overall aim in this work is to present a cross-cultural bioethics study through the investigation of some ethical issues in AIDS in China from a Chinese-Western comparative perspective and also attempt to suggest a humane and effective policy for HIV/AIDS which I believe is appropriate to both traditions. I believe this work has contributed to our knowledge in three related but independent areas: the control of the epidemic of HIV/AIDS in China; medical ethics in China; and to both the methods and the utility of cross-cultural study of bioethics between China and the West. (shrink)