Schools of medicine began. There were 7 schools of medicine in
the two periods spanning between 770 and 221 B.C. There were popular
doctors with numerous disciples. These schools and groups developed
into non-governmental medical organizations which resulted in
the development of medical ethics.
The Six Taboos
One popular doctor, Bian Que set forth the earliest code of medical
ethics in China, The 6 Taboos.
"Medicine should not be offered in six circumstances
- People who had unreasonable arrogance and indulgence,
- People who appreciated riches more than life,
- People who couldn't even keep body and soul together,
- People who were suffering from interlocking Yin and Yang,
- People who were too weak to take medicines, and
- People who didn't believe in medicine but in sorcery."
Ethics as Protection for Physicians
The main reasoning behind these taboos was to take into account
the complexity and severity of the patient's disease, the likelihood
of the patient sabatoging the doctor's efforts, and the limitations
of the doctors' therapies.
In ancient China, physicians were rather independent. They were
wanderers without formal training, licensing, or officiating bodies.
This meant that there were not only righteous and excellent doctors,
but also quacks and incompetents. The consequences of poor care
were often severe for the doctors. Failing to cure an Emperor
could lead to execution.
To protect themselves, doctors emphasized both prognosis and
codes of conduct. Knowing the future course of a disease (prognosis)
helped physicians choose which cases to treat and which ones to
refuse. Following a good code of ethics meant that, in cases of
failure, the doctor had done all he should and was beyond reproach.
The Influence of Confucianism on Chinese Medical
From the Han Dynasty on, Confucianism took over Chinese values.
This influence put more emphasis on the value of caring for patients.
Physicians were expected to cultivate themselves.
Benevolence, or loving people, is the core of Confucian
ethics. Confucianists believed that medicine, whose purpose was
to save lives, was the ultimate expression of saving people via
love. The great Zhong Zhang Jin (writer of the Shang Han Lun,
the earliest systematic herbal text) said that Confucians could
realize their goal of loving people if they only grasped medical
theories and treated people attentively. This is the origin of
the saying "Medicine is the Art of Humanity"
Benevolence requires the veneration of human life. Nothing
was more valuable. The great physician Sun Simiao said that people's
lives were worth more than gold. Confucians were rigorous and
painstaking in their diagnosis so that they would avoid doing
harm. Thus, Mencius said, "In medicine, benevolence means
causing no harm to patients."
Benevolence also called for respecting patients. It would
be improper for the doctor to act as if he'd done his patients
a favor; care was his duty, the ultimate expression of humanity.
Requiring money or sex for care was out of the question.
Confucianism also dictated a universality of care. No
patient should be given better or worse care on the basis of status,
money, appearance, age, race, or mental ability. Tianchen Li,
a Ming Dynasty physician, suggested "We should treat the
patients as our mothers." This is in accord with the Confucian
Confucius believed everyone had a conscience, an inborn sense
of right and wrong. In physicians, this would lead to another
1. The Sense of Pity: Compassion and love for the patient.
2. The Sense of Shame: The doctor would feel shame if he
|a. put his interests ahead of his patient,
b. reached a diagnosis without performing all 4 physical examination
c. abused medicines, or
d. deceived a patient
3. The Sense of Respect
4. The Sense of Right and Wrong: Do not damage the patient's
The way that Confucian physicians practiced self-cultivation
was through self-examination, self-criticism, and self-restriction.
Confucius proposed that instead of trying to set up a universal
code of behavioral guidelines, each person should subject themselves
to self-examination. This is one major reason for the lack of
codified medical ethics in Chinese Medicine.
Other Influences on Chinese Medical Ethics
Ancient China was not highly organized. It was an agricultural
economy, and the main social unit was the family. Consequently,
medicine was passed down familial lines. The education was not
standardized. There was little or no competition between professionals.
There was not the same great need for universal ethical guidelines
that comes in more socially interactive cultures.
Taoism and Buddhism also influenced Chinese Medical Ethics. Taoism's
greatest value and goal was immortality. Among the ways to achieve
this were taking miraculous herbs and practicing good deeds upon
others. The latter idea fit with Buddhism's emphasis on cultivating
"good karma" by right action toward others.
The History of Western Medical Ethics
Western Medical ethics began with Hippocrates. He founded
a medical school and required his students to take an Oath. The
main ideas of the Hippocratic Oath were:
- Honor medical instructors and their offspring.
- Pass on medicine only to those bound by the Oath.
- Practice medicine for the benefit of patients. Do no harm.
- Give no deadly medicine or substance to produce abortion.
- Abstain from mischief and corruption.
- Doctor-patient confidentiality
In 1794, Thomas Percival (an English physician noted for
his care of the poor) published a code of medical ethics that
later was adopted by the AMA. The main points were the moral authority
and independence of physicians, responsibility to care for the
sick, and individual honor.
The AMA Code of Ethics was adopted in 1847. In the 1840's,
people could call themselves medical doctors after just a 3 month
course (doesn't that remind you of how MD's can now practice acupuncture
after a similar length of study? Can you say "hypocritical?").
This code was so powerful that it almost tore the AMA in two 20
years later. The AMA revised their code in 1980, and then again
Another significant development occurred after WWII. The Nuremberg
trials, in response to experiments performed by the Nazis, led
to The Nuremberg Code. It was meant to protect patients
involved in research studies. The most important of these 10 principles
are voluntary consent, the ability of the patient to end their
participation at any times, and protection of the patient against
The next development was the 1948 Declaration of Geneva,
from the World Medical Association. It was meant to update the
Hippocratic Oath, which was seen to be both outdated and not comprehensive.
It also was a reaction to Nazi atrocities.
"At the time of being admitted as a member
of the medical profession I solemnly pledge myself to consecrate
my life to the service of humanity: I will give to my teachers
the respect and gratitude which is their due; I will practice
my profession with conscience and dignity; The health and life
of my patient will be my first consideration; I will respect
the secrets which are confided in me; I will maintain by all means
in my power, the honor and the noble traditions of the medical
profession; My colleagues will be my brothers: I will not permit
considerations of religion, nationality, race, party politics
or social standing to intervene between my duty and my patient;
I will maintain the utmost respect for human life, from the time
of its conception, even under threat, I will not use my medical
knowledge contrary to the laws of humanity; I make these promises
solemnly, freely and upon my honor..."
(my boldings to highlight the new ideas)
In 1964, the World Medical Association released the Declaration
of Helsinki. It was also meant to protect research subjects.
It contains 22 principles- too many to list here. It has been
revised in 1975, 1983, 1989 and 1996 and is the basis for Good
Clinical Practices used today.
Medical ethics as a field of study in the U.S. has really grown
up in just the last 30 years. In the 1950s the progress of medicine
was seen as something that could not end. In the 60's opinions
changed; MD's had long opposed to reforms to medical care financing,
which they stigmatized as "socialized medicine." People
began to see MD's and the AMA as greedy, uncaring, and self-interested.
With the rise of "alternative medicine," MD's have
seen patient en masse deserting their western "traditional"
care. They are slowly awakening to the fact that people want
physicians who care. They also are rejecting some of the limitations
of western medical therapies. However, it is easier to change
the former problem.
Now, many physicians feel that reform in the medical ethics realm
is the MD's only hope of survival. George Lundberg, MD (former
AMA president and CEO of Medscape) thinks of his own profession
potentially terminal. He states that medical ethics is the most
popular writing topic for submissions to the Journal of the American
Comparison between the Two Ethical Systems
Both cultures developed ethics as an extension of becoming 'professions.'
Traditionally, the three learned (scholarly) professions are
law, religion, and medicine. These are callings to which are trusted
"the most private and intimate secrets of a person's mind,
soul, and body" (Lundberg).
Ancient China was much less socially grouped than ancient
Greece. In the Middle Ages of the West, political and social groups
were very important. Doctors organized unions voluntarily. They
developed apprenticeships and tried to avoid internal competition.
While the West constructed social codes, China emphasized personal
The Confucian concept of benevolence is similar to the
Hippocratic 'do no harm.' In fact, there are many parallels
between the AMA's revised principles (which is the latest outgrowth
of thousands of years of Western philosophy and medicine) and
Chinese medical ethics.
Western Civilization was inherently more likely to develop a
set of ethical guidelines than Chinese culture. Western civilization
and its religions are highly legislative and literal.
It creates guidelines which are fixed, absolute, and eternal.
These guidelines are often kept in a book or document such as
the Bible, the U.S. Constitution, or the AMA's Principles of Medical
In China, Taoist natural spontaneity, Buddhist sudden
enlightenment and Confucian self-cultivation combined
to repel the idea of absolute standards. Of course, this is not
wholly true; Christian "living in the Spirit" can be
totally spontaneous, Jesus was a homeless wanderer led by God,
Buddhism has 4 noble truths and an 8-fold path, Confucius wrote
the Analects, and Lao Tzu wrote the Tao Te Ching (an oxymoron
- the way that cannot be named can be written in a book?).
Medicine and Money
Confucianism's disgust with monetary reward left it open
to socialism. In socialized medicine, doctors are not paid as
well as their western counterparts. The thin line between altruism
and greed is a major ethical dilemma in western medicine (this
includes the western practice of chinese medicine).
I recently heard a story of a newly graduated student of Chinese
medicine in Los Angeles. A patient had called to find out if they
had been treated well. Details aside, the doctor was both incompetent
and negligent. Not only that
he charged $140 for the first
visit, and $90 for return visits. That's a high price - period
let alone for incompetency.
George Lundberg, MD suggests that students enter western medicine
for 4 reasons:
- To be of service
- Because they're good at science
- To have a good deal of independence
- To make money
The first three are good reasons. The fourth is dangerous.
A Table of Comparisons between Western and Chinese
The AMA's Revised Principles of Medical
Ethics, June 2001
Western Medical Ethics History
Chinese Medical Ethics History
|A physician shall be dedicated
to providing competent medical care, with compassion and respect
for human dignity and rights.
The Sense of Pity, The
Sense of Shame
|A physician shall uphold the
standards of professionalism, be honest in all professional
interactions, and strive to report physicians deficient in
character or competence, or engaging in fraud or deception,
to appropriate entities.
The Sense of Shame
|A physician shall respect the
law and also recognize a responsibility to seek changes in
those requirements which are contrary to the best interests
of the patient.
|A physician shall respect the
rights of patients, colleagues, and other health professionals,
and shall safeguard patient confidences and privacy within
the constraints of the law.
The Sense of Respect
|A physician shall continue to
study, apply, and advance scientific knowledge, maintain a
commitment to medical education, make relevant information
available to patients, colleagues, and the public, obtain
consultation, and use the talents of other health professionals
|A physician shall, in the provision
of appropriate patient care, except in emergencies, be free
to choose whom to serve, with whom to associate, and the environment
in which to provide medical care.
The 6 Taboos
|A physician shall recognize
a responsibility to participate in activities contributing
to the improvement of the community and the betterment of
|A physician shall, while caring
for a patient, regard responsibility to the patient as paramount.
The Sense of Shame, The
Sense of Respect
|A physician shall support access
to medical care for all people.
1. Benfu Li, Medical Ethics (Beijing: Peking Union Medical College
and Beijing Medical University Press, 1996), 41-42.
2. Bocong Li, On Bianque and the School of Bianque (Xian: Shanxi
Science and Technology Press, 1990).
3. Declaration of Geneva. Adopted by the General Assembly of World
Medical Association at Geneva Switzerland, September 1948.
4. DECLARATION OF HELSINKI: Ethical Principles for Medical Research
Involving Human Subjects Adopted by the 18th WMA General Assembly
Helsinki, Finland, June 1964 and amended by the 29th WMA General
Assembly, Tokyo, Japan, October 1975; 35th WMA General Assembly,
Venice, Italy, October 1983; 41st WMA General Assembly, Hong Kong,
September 1989; 48th WMA General Assembly, Somerset West, Republic
of South Africa, October 1996; and the 52nd WMA General Assembly,
Edinburgh, Scotland, October 2000.
5. Lia Chen, Ancient Religions and Ethics (Life, Reading and New
Knowledge, 1996), 7.
6. Lundberg, George D., MD. Severed Trust: Why American Medicine
Hasn't Been Fixed. Basic Books, 2000.
7. Miraculous Pivot (Beijing: People's Health Press, 1963).
8. Nuremberg Code [from Trials of War Criminals before the Nuremberg
Military Tribunals under Control Council Law No. 10. Nuremberg,
October 1946-April 1949. Washington, D.C.: U.S. G.P.O, 1949-1953.]
9. Qian Sima, Records of History: Biography of Bianque and Canggong.
10. Simiao Sun, Essential Prescriptions Worth a Thousand Gold
in Hua Fan's History of Late Han Dynasty: Records of Crafts (Beijing:
People's Health Press, 1982), 476.
11. Shuming Liang, Essence of Chinese Culture (Shanghai: Xuelin
Press, 1987), 69.
12. Unschuld P., Medical Ethics in Imperial China (University
of California Press, 1979), 5-10.
13. Yimo Zhou, ed. Famous Physicians' Addresses on Medical Ethics
(Changsha: Hunan Science and Technology Press, 1983), 212
14. Zhang and Cheng. Medicine is a Human Art: The Basic Principles
of Professional Ethics in Chinese Medicine. Medical History Research
Center, Beijing Medical University.
15. Zhongjing Zhang, A Treatise on Febrile and Miscellaneous Diseases
(Beijing: People's Health Press, 1963).
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